Biopuncture

Name *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Main Phone Number *

Secondary Phone Number

Date of Birth *

Age *

Gender *

Height *

Current Weight *

Marital Status *

Do you have any children?

Yes
No

Personal Health and Lifestyle

Describe the symptoms you are currently experiencing: *

List any and all specific diagnoses you have received in the past 20 years: *

List any and all specific surgeries/treatments you have received in the past 20 years: *

What would you like to accomplish/gain from this consultation? *

Do you drink caffeinated drinks? *

Yes
No

If so, how much and how often?

Do you currently smoke? *

Yes
No

If so, how much and how often?

Have you ever smoked? *

Yes
No

If you have quit smoking, why, how, and when did you quit?

Do you drink alcohol? *

Yes
No

If so, how much and how often?

Do you drink soda (diet or regular)? *

Yes
No

If so, how much and how often?

Have you received standard childhood vaccinations and boosters? *

Yes
No

Have you received Covid Vaccinations? *

Yes
No

If so, which manufacturer and how many boosters and when did you receive them?

Have you had any flu or shingles vaccinations? *

Yes
No

If so, which ones and when?

What role does exercise play in your life? *

How much water do you drink per day? *

Please list any doctor-recommended or prescribed medications, creams, supplements, or vitamins you are currently taking (for any reason). Also include any over-the-counter products you are currently taking:

Do you have any known allergies to medications or herbs? *

Yes
No

If so, please list all below:

Do you have any food allergies? *

Yes
No

If so, please list all below:

Are you currently under a practitioner's care for a specific health issue? *

Yes
No

If so, what treatments are you undergoing?

Please list any surgeries, accidents, injuries, or childhood diseases you have had, along with the type and approximate date:

What are your current eating/drinking habits? *

What are your current eating/drinking habits for lunch? *

What are your current eating/drinking habits for dinner? *

What are your current eating/drinking habits for snacks? *

What are your current drinking habits? *

What percentage of your food is home cooked? *

How often do you eat out? *

Do you crave sugar? *

Do you crave salt? *

Do you feel tired, bloated, and/or gassy after meals? *

Do you experience constipation or diarrhea? *

Do you feel excessively hungry? *

Do you have a poor appetite? *

Please list any known food allergies and/or intolerances:

Family Health History

List anyone in your family who has suffered from...

List anyone in your family who has suffered from heart disease

List anyone in your family who has suffered from kidney disease

List anyone in your family who has suffered from asthma

List anyone in your family who has suffered from arthritis

List anyone in your family who has suffered from gallbladder disease

List anyone in your family who has suffered from intestinal disorders

List anyone in your family who has suffered from cancer

Mother's Age

If your mother is no longer living, what did she die from?

Father's Age

If your father is no longer living, what did he die from?

Maternal Grandmother's Age

If your grandmother is no longer living, what did she die from?

Maternal Grandfather's Age

If your grandfather is no longer living, what did he die from?

Paternal Grandmother's Age

If your grandmother is no longer living, what did she die from?

Paternal Grandfather's Age

If your grandfather is no longer living, what did he die from?

THIS SECTION IS FOR WOMEN ONLY

How old were you when you got your first period?

Are your periods regular?

How frequent are your periods?

How many days is your flow?

How many pregnancies have you had?

Do you experience PMS?

If so, is it mild or severe?

Are you peri-menopausal?

Yes
No
Unsure

If so, when did this change first occur?

Are you menopausal?

Yes
No
Unsure

If so, when was your last period?

List your symptoms of peri/menopause:

How many children have you delivered, and how were they born (vaginally or by cesarean)?

Were there complications associated with these births? If so, please explain:

Did you receive antibiotics during labor?

Yes
No
N/A

Have you ever had a miscarriage?

Yes
No

If so, how many?

Have you ever had an abortion?

Yes
No

If so, how many?

Please check if any of the following conditions currently apply to you:

GROUP A

GROUP B

GROUP C

GROUP D

GROUP E

GROUP F

Please let us know if you would like to receive information or learn more about any of these following modalities that we recommend incorporating into your care:

Please check below to indicate that you have read and understand that you cannot be seen for your Initial Consultation unless the following requirements are met: *

I understand the requirements needed in order to be seen for my Initial Consultation *

By checking above, you are indicating that you have read and understand that you cannot be seen for your Initial Consultation unless the following requirements are met:
(1) this New Client Form must be completed and submitted; (2) the Nutritional Questionnaire (separate from this form) must be completed; (3) your current medications and supplements must be brought to your Initial Consultation.

SIGN BY TYPING YOU NAME BELOW TO ATTEST TO THE FOLLOWING: I have read, acknowledged, and agree to the Agreement and Release of Liability: *

Please click HERE to read our Agreement and Release of Liability. Then, sign by typing your full name in the box above. By signing, you are acknowledging that you have read and accept the terms and conditions of the disclaimer.

Personal Health and Lifestyle

Family Health History

THIS SECTION IS FOR WOMEN ONLY

Please check if any of the following conditions currently apply to you:

For more information or to schedule a consultation, contact us today!

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