New Client Health History

Please complete this form before your first appointment. All information is kept strictly confidential.

Personal Information

First Name*

Last Name*

Date of Birth

Phone*

Email Address*

Street Address

City

State

ZIP Code

Emergency Contact Name

Emergency Contact Phone

What is the primary reason for your visit today?*

How long have you been experiencing this?

Past or current medical conditions / diagnoses

Previous surgeries (include approximate year)

Previous hospitalizations

Current prescription medications (name, dose, frequency)

Current vitamins, supplements, or herbal remedies

Known allergies (medications, foods, environmental, other)

Significant health conditions in immediate family members (parents, siblings, children)

Describe your typical diet

Exercise habits

Average hours of sleep per night

Stress level (1 = low, 10 = very high)

Anything else you'd like us to know before your appointment?

Fields marked * are required. All information is kept strictly confidential.