Client Health History Intake Form

Section 1: Personal Information

First name

Email

Address

Phone #

Date of Birth

Month

Day

Year

Emergency Contact Name

Emergency Contact Phone #

Primary Care Provider Name

Primary Care Provider Practice

List major surgeries or recent hospital visits

Medication allergies

Food/environmental allergies

Include prescriptions, OTCs, supplements, vitamins:

Do you smoke?

Alcohol use

Recreational drug use

Would you like us to communicate with your primary provider or specialist if needed?

Yes, I give permission

No

Client Signature

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Date