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New Client Forms

Clinical Nutrition Center

NEW PATIENT INFORMATION FORM

Page 1 of 2

Please print clearly:

Name_______________________________________________ Date______________

Address______________________________________________ Apt.#_____________

City_______________________________ State____________ ZIP_______________

Shipping Address__________________________________________________________

________________________________________________________________________

Home Phone (____) ____-_________ Work Phone (____) ____-_________

e-mail address: _______________________________________

REFERRED BY:_________________________________________________________

Occupation _________________________ Employer____________________________

Date of Birth__________________ Age ____ Sex: M/F Height _____ Weight _____

Overall health (circle one): Excellent / Good / Fair / Poor / Other:_______________________

Chief complaint (reason you are here): (use separate sheet if more room needed)

________________________________________________________________________

Previous treatments for this complaint___________________________________________

________________________________________________________________________

Other complaints or problems: (use separate sheet if needed)__________________________

________________________________________________________________________

Current medications/drugs being taken: (use separate sheet if needed)___________________

________________________________________________________________________

Are you currently under the care of a physician or other health care professionals?

(If yes, please give name and date of last visit):

________________________________________________________________________

Nutritional supplements you are taking:__________________________________________

Do you smoke, drink coffee or alcohol? (if yes indicate how much)

Cigarettes _______________ Coffee__________________ Alcohol________________

===============================================================

Office Use Only:

NewClient 7/01

Clinical Nutritional Healing Center

NEW PATIENT INFORMATION FORM

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Name:_______________________________________________ Date______________

HISTORY:

List any major illnesses (with approx. dates):______________________________________

________________________________________________________________________

List any surgery or operations with approx. date:___________________________________

________________________________________________________________________

Past Accidents or injuries:____________________________________________________

________________________________________________________________________

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Marital Status: S M D W Name of Spouse_____________________________

Describe health of spouse:_________________________ Number of children if any _____

Name of Child Age Sex Any physical conditions or concerns?

_________________________ ____ M/F _________________________________

_________________________ ____ M/F _________________________________

_________________________ ____ M/F _________________________________

Any family history of serious illnesses (circle those which apply): Cancer / Diabetes / Heart / Other

Any household pets or other animals you or family members are in close contact with:

________________________________________________________________________

What can we do to make you happier?__________________________________________

________________________________________________________________________

SIGNED:_____________________________________________ DATE_____________