NATURCHEM HEALTH SYSTEMS
16409 SE DIVISION, Suite #216-192
Portland, OR 97236

                         CLIENT HISTORY FORM

Name___________________________________ Age_____ Sex_____ Date__________

Address_________________________________ DOB__________ Phone______________

City_____________________________ State_______ Zip__________________________

Social Security No._____________________ Ht______ Wt_________ BP_____________

Occupation: ____________________________ Hobbies: ____________________________

List major complaints in order of importance: Explanations:

1.______________________________________ ___________________________________

2.______________________________________ ___________________________________

3.______________________________________ ___________________________________

4.______________________________________ ___________________________________

5.______________________________________ ___________________________________

6.______________________________________ __________________________________

7.______________________________________ __________________________________

8.______________________________________ __________________________________

9.______________________________________ __________________________________

10._____________________________________ __________________________________

11._____________________________________ __________________________________

12._____________________________________ __________________________________

List Diet:

Medications:

Medical History: