BYRNE CHIROPRACTIC AND WELLNESS CENTER

NEW NATUROPATHY CLIENT INFORMATION FORM

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Please print clearly:

Name ______Date ______

Address ______Apt.# ______

City ______State ______ZIP ______

Cell Phone (_____) _____ - ______Is it okay to send text messages? Yes__ No__

Home Phone (_____) _____ - ______Work Phone (_____) _____ - ______

E-mail Address ______

*REFERRED BY: ______

Your Occupation ______Employer ______

Date of Birth ______Age ______Gender: Male/Female

Overall Health (circle one): Excellent / Good / Fair / Poor / Other ______

Chief Complaint (the reason you’re here) ______

Previous treatments of this complaint ______

Other complaints or problems ______

Are you currently under the care of a physician or other healthcare professional?

Physician Name ______Date of last visit ______

Current Medications/drugs/nutritional supplements ______

______

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BY NOT DISCLOSING ALL MEDICATIONS, YOU MAY BE AT HIGHER RISK FOR HERBAL AND MEDICINE INTERACTIONS. PLEASE INTIAL THAT YOU HAVE READ AND ACKNOWLEDGE THIS STATEMENT. ______

Do you smoke/vape/chew tobacco? Do you drink coffee or alcohol? (if yes, indicate how much and how often)

Cigarettes, cigars, etc. ______Coffee ______Alcohol ______

NEW CLIENT NATUROPATHY INTAKE

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List any major illnesses (with approx. dates) ______

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List any surgery or operations (with approx. dates) ______

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Past Accidents or injuries ______

Marital Status: Single/Married/Divorced/Widowed Name of Spouse ______

Describe Health of Spouse ______Number of children, if any ______

Names of Immediate Family Age Gender Any physical conditions or concerns?

______Male/Female ______

______Male/Female ______

______Male/Female ______

______Male/Female ______

Any family history of serious illness (circle all that apply) Cancer / Diabetes / Heart / Other ______

Any household pets or other animals you or your family members are in close contact with ______

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What can we do to make you happier? ______

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CONSENT

IMPORTANT: By signing below, I understand that the suggested nutritional program and dietary information is not intended as primary therapy for any disease or symptom. My intention is to find a good nutritional program that will assist me in changing my habits and establishing a new lifestyle in order to build good health naturally. I understand that this dietary health program is not for the diagnosis, cure, mitigation, treatment or prevention of disease; this is an adjunctive schedule of nutrients solely provided to upgrade the quality of foods in my diet in order to supply good nutrition for supporting the physiological and biochemical processes of the human body.

I fully understand that the naturopathic practitioner I am visiting is not a medical doctor (MD) and does not treat or diagnose medical conditions; that is not a replacement for medical counseling; that if I have a medical condition, I will seek a licensed professional of allopathic/orthodox medicine. I agree I am not seeking specific treatment, but an overall increase in my health status. I accept this information and agree to the conditions specified.

I am not on this visit or any subsequent visit an agent for federal, state, or local agencies or on a mission of entrapment or investigation.

I understand that it is my personal decision whether or not to follow the natural health recommendations offered.

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PATIENT / AUTHORIZED PERSONS SIGNATURE

Signature: ______Date ______