About You

Today’s Date: / /   File #:

Name:

What You Prefer To Be Called:       Gender:    Male      Female

Birth date: / / Age:

Mailing Address:

City: State:  Zip:

Home Phone #: Other Phone #’s:

Referred By:

Employer: How Long:

Employer’s Address: City: State: Zip:

Occupation: Work  Phone #:

Marital Status (Please Circle):   Single      Married      Divorced      Separated     Widowed

Spouse’s Name:

Reason For Visit

Have you ever been to a Holistic Health Practitioner?  Yes  No

If so, whom? Phone #:

The reason for this visit is a result of (Please Circle): Work Sports Auto Trauma Chronic

(Explain what happened) :

Please describe the pain & its location:


When did the condition being? / /

Is this condition getting worse? Yes  No Constant Comes and goes

Is this condition interfering with your (Please Circle):  work sleep daily routine

If so, please explain:

Have you had this or similar conditions in the past?  Yes No

Have you been treated by a Medical Physician for this condition? Yes No

If so, where?

In Event of Emergency

Emergency Contact Name:

Emergency Contact Phone #:

Health History

Are you taking any of the following medications (Please check)?

Nerve Pills Pain killers (including aspirin) Muscle relaxers Stimulants

Blood Thinners Tranquilizers Insulin Others:

Have you ever had any of the following diseases/medical conditions?

Heart Attack / Stroke Heart Surg./Pacemaker Heart Murmur Congenital Heart Defect

Mitral valve prolapse Artificial Valves Alcohol / Drug Abuse Venereal Disease Hepatitis

HIV+ / Aids Shingles Cancer Frequent Neck Pain Emphysema / Glaucoma Anemia

High/Low Blood Pressure Psychiatric Problems Rheumatism Fever Severe/Frequent

Headaches Kidney Problems Ulcers / Colitis Fainting/Seizures/Epilepsy

Sinus Problems Asthma Diabetes / Tuberculosis Difficulty Breathing Chemotherapy

Lower Back Problems Artificial Bones / Joints Arthritis

Please list any other serious medical condition(s), you have or ever had:


Please list anything that you may be allergic to:

List any past serious accidents with dates:


Family Health History:


Do you smoke? No Yes  / How much? How long?

Are you wearing (Please Circle): Heel Lifts Sole Lifts Inner soles Arch supports

What is the age of your mattress?    Is it comfortable? Yes No     

For Women:  Are you taking Birth Control? Yes No

Are you Pregnant? No Yes / How long?   Nursing? Yes No

Account Info

Person ultimately responsible for account:

Name: Relation:

Billing Address:   City: State:  Zip:

Work Phone #: