Natural Health Improvement Center
NEW CLIENT INFORMATION FORM

Please print clearly:

Name ______________________________________________ Date ___________________

Address _____________________________________________________ Apt.# _________

City __________________________________ State _______________ Zip _____________

Shipping Address: ____________________________________________________________

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Home Phone: (______) _______-___________ Work Phone: (______) _______-__________

REFERRED BY:___________________________________________________________

Occupation __________________________ Employer ______________________________

Date of Birth: ______________ Age: _____ Sex: M/F: ____ Height: _______ Weight _______

Overall health (circle one): Excellent / Good / Fair / Poor / Other:_________________________

Chief complaint (reason you are here) (use separate sheet if more room needed)
__________________________________________________________________________

Previous treatments for this complaint: _____________________________________________

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Other complaints or problems: (use separate sheet if needed) ____________________________

__________________________________________________________________________

Current medications/drugs being taken: (separate sheet if needed): ________________________

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Are you currently under the care of a physician or other health care professionals?   (If yes, please give name and date of last visit):__________________________________________________

Nutritional supplements you are taking:_____________________________________________

Do you smoke, drink coffee or alcohol? (If yes, indicate how much):
Cigarettes: __________________ Coffee__________________ Alcohol _________________
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HISTORY:
List any major illnesses (with approx dates): _________________________________________
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List any surgery or operations with approx date: _____________________________________
__________________________________________________________________________

Past accidents or injuries: ______________________________________________________
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Marital Status:  S    M    D    W     Name of Spouse:___________________________________

Describe health of spouse: __________________________ Number of children, if any: _______