Client History Form

SSI# or PIN # :_______________________ Received:___ ID~Stamp(given):____________________ Date: ___________

Name:____________________________________ Age:_____ Sex:___ Race:_____________________________________

Address:__________________________________ DOB:_____________ Ph:______________ Wk Ph:________________

City:_____________________________ State:_____Country:_____________ Zip:________________________________

Fax Number:________________ E-mail:_______________URL:_______________________________________________

Height:______ Weight:______Wt.(6 months ago):_______ Rt BP:___________Lt BP:___________Heart Rate:________

Sexually active:____ How often?_______ Enjoy:____ How many meals per day?_____________Smoke:____Drink:____

Occupation/Hobbies:_____________________________Medications:___________________________________________

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Habits:_______________________________________________________________________________________________

Comments:____________________________________________________________________________________________

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List major Complaints in order of importance: Explanations:

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