New Client Questionnaire (Adult)

Today's Date

Client Information

First name

Last name

Home phone number

Cell phone number

Email address

Date of birth

Have you been treated by a doctor in the last 12 months?

Yes No

If yes, please describe the reason for your visit

Date of your last physical exam

Please list the medications you are taking and for what conditions. Include the dosage and amounts.

Sex

Male Female Other

Street Address

City, State, Zip

Marital Status

Single Married

Member

Self Other

Self: Birthdate

If Other: Birthdate

Insurance Carrier

Member ID

Employer

Insurance Deductible (if none, put 0)

Co-payment/Co-insurance

Deductible Met

Yes No