New Client Intake - Custom Wellness

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Home
- Disclaimer
Espanol
Workshops
Reviews
Contact
- Contact
- Hours
Book an Appointment
Blog
Careers
Sign-up

New Client Intake

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Landline *

Cell Phone *

Work *

Which number above is the best to reach you? *

Landline Cell Phone Work

Would you like your cell phone number to be added to our texting service for upcoming events? *

Yes No

How did you hear about us? *

ex: person's name, internet

Email *

Would you like to be added to our email list for upcoming events? *

Yes No

Status *

Client's Information

Name *

Date of Birth *

Age *

Occupation *

Height *

Weight *

Person Responsible for Payment (Guarantor)

Name *

Date of Birth *

Age *

Occupation *

Phone Number *

Spouse Information

Name *

Date of Birth *

Age *

Phone Number *

In Case of Emergency

Name *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Have you ever had muscle testing done? *

Yes No

With Whom *

Number 1 concern *

What is the date of the first occurrence of this problem? *

What have you done to alleviate this problem/pain/discomfort? *

Have you seen a medical doctor, osteopath, or naturopath for this problem? *

Yes No

Name of Doctor seen for this problem *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

What tests were taken (and approx. dates)? *

Please list your major concerns in order of importance *

Secondary concerns *

Please list any injuries and approximate dates *

Please list any surgeries and appropriate dates *

What medications are you taking? *

What vitamins, minerals or other supplements are you currently taking? *

Mother *

Living Deceased

Father *

Living Deceased

Please Answer the following for each family member

Father *

Diabetes Cancer TB Heart Disease High Blood Pressure Low Blood Pressure Hyperglycemia None

Other *

Mother *

Diabetes Cancer TB Heart Disease High Blood Pressure Low Blood Pressure Hyperglycemia None

Other *

Sister *

Diabetes Cancer TB Heart Disease Low Blood Pressure Hyperglycemia None

Other *

Brother *

Diabetes Cancer TB Heart Disease High Blood Pressure Low Blood Pressure Hyperglycemia None

Other *

Daughter *

Diabetes Cancer TB Heart Disease High Blood Pressure Low Blood Pressure Hypoglycemia None

Other *

Son *

Diabetes Cancer TB Heart Disease High Blood Pressure Low Blood Pressure Hypoglycemia None

Other *

List all past and current disease for yourself, including childhood. Include dates. *

List all car accidents and all major falls or injuries, including childhood. Include dates *

How much water do you drink per day (in ounces)? *

You weight (lbs)? *

Number of time your urinate during the...

Day *

Night *

How often do you have a bowel movement? *

Do you have sufficient energy for your normal activities? *

Yes No

Are you under emotional stress? *

Yes No

Explain *

Are you under other types of stress? *

Yes No

Explain *

Do you have any allergies? Please list. *

Do you exercise? *

Yes No

What type of exercises and how often each week? *

Any major changes to your diet in the last four months? If yes, please explain. *

What is your typical breakfast? *

Do you...

Smoke? *

Yes No

How much? *

Drink alcohol? *

Yes No

How much *

Drink soda? *

Yes No

How much? *

Drink Coffee *

Yes No

How much? *

Have food cravings? *

Yes No

What/When? *

Female Patients

Date of last menstrual period *

How often do you menstruate? *

Do you experience menstrual discomfort? If yes, explain. *

List any menopause symptoms you are experiencing? *

When did menopause symptoms start? *

Male Patients

Frequent Urination *

Yes No

Urgency *

Yes No

Have you been treated with an anti-biotic for your prostate? *

Yes No

Have you been told you have an enlarged prostate? *

Yes No

Additional comments or questions *

Submit

After you have submitted the New Client Intake form, next please fill out the Sympton Survey Form.

348 South Waverly Rd., Suite 220
Holland, MI 49423

(616) 294-3475
english and español

contactus@customwellnessholland.com

Custom Wellness serves the West Michigan and Lakeshore area.

Copyright © 2017-2020 Custom Wellness, LLC. All Rights Reserved.