Client Information Form

Form 1: Client Information Form

Name: E-mail:

Spouse’s Name: Emergency Contact Phone Number:

If client is Minor - Parents’ Names:

Home Address:

City: State: Zip:

Mailing Address:

City: State: Zip:

Home Phone (with area code): Work Phone (with area code):

Employer: City: Profession:

Birth Date: Referred by:

Primary Care Physician: City: Phone Number (with area code):

Check any of the following medications you are taking or have taken within the last 90 days:

Antacids

Cortisone/Anti-inflammatories

Lithium

Antibiotic/Antifungal

Heart Medications

Oral Contraceptives

Antidepressants

High Blood Pressure

Radiation

Antidiabetic/Insulin

Hormones

Relaxants/Sleeping Pills

Aspirin/Tylenol

Inhalers

Thyroid

Chemotherapy

Laxatives

Ulcer Medications

Recreational Drugs
Specify:

Other
Specify:

Check if you eat, drink, or use:

Alcohol

Distilled water

Refined sugars

Candy

At fast food restaurants regularly

Saccharine (artifical sweeteners)

Carbonated beverages

Fried foods

Chew tobacco

Cigarettes

Luncheon meats

Vitamins and/or Minerals

Coffee

Margarine

Check if you:

Diet often

Salt food without tasting

Are exposed to chemicals at work

Do not exercise regularly

Are under excessive stress

Are exposed to cigarette smoke

List all medications taken within the past 90 days:

List all supplements:

Do you have a history of any of the following:

High blood pressure
Yes No

Low blood pressure
Yes No

Elevated blood sugar levels
Yes No

Low blood sugar levels
Yes No

Family history of diabetes:

    Father’s side:
Yes No

    Mother’s side:
Yes No

    Both:
Yes No

Family history of cancer. If yes, what type:

Yes No

Any hereditary condition. If yes, describe.

Yes No

Heart problems. If yes, what type:

Yes No

Please list below the five main complaints you have in the order of importance:

List any allergies (food, chemicals, medications, supplements, environmental, pets):

***IMPORTANT***

Click the button below to print this form, then sign and mail it to us with a recent photo of yourself.
You should also print this as a backup and for your own personal records.

******

Antacids	Cortisone/Anti-inflammatories	Lithium
Antibiotic/Antifungal	Heart Medications	Oral Contraceptives
Antidepressants	High Blood Pressure	Radiation
Antidiabetic/Insulin	Hormones	Relaxants/Sleeping Pills
Aspirin/Tylenol	Inhalers	Thyroid
Chemotherapy	Laxatives	Ulcer Medications

Alcohol	Distilled water	Refined sugars
Candy	At fast food restaurants regularly	Saccharine (artifical sweeteners)
Carbonated beverages	Fried foods	Chew tobacco
Cigarettes	Luncheon meats	Vitamins and/or Minerals
Coffee	Margarine

Diet often	Salt food without tasting	Are exposed to chemicals at work
Do not exercise regularly	Are under excessive stress	Are exposed to cigarette smoke

High blood pressure	Yes	No
Low blood pressure	Yes	No
Elevated blood sugar levels	Yes	No
Low blood sugar levels	Yes	No
Family history of diabetes:
Father’s side:	Yes	No
Mother’s side:	Yes	No
Both:	Yes	No
Family history of cancer. If yes, what type:	Yes	No
Any hereditary condition. If yes, describe.	Yes	No
Heart problems. If yes, what type:	Yes	No