Center Of Harmony Confidential Client Application

Please fill in the following questions before your appointment.

Full Name *

Phone *

Email *

Place of Birth

Address

Postal code

State

Spouse/Partner Name

Relationship Status

Single

Married

Partner

Separated

Divorced

Widow/Widower

Height

Weight

City

Occupation

DOB *

Number of Children

Emergency Contact *

Do you enjoy your job?

Yes

No

Primary Reason For Your Visit:

Have others helped you with this problem?

What are your expectations after the sessions?

Who can we thank for you being here (who referred you)?

Metabolism

Weight gain

Weight loss

High/Low blood pressure

Blood sugar

Thyroid

Dental

Tooth problems

Root canals

Amalgam fillings

Difficult chewing

TMJ

Chest

Chest pain

Palpitations

Cough

Shortness of breath

Asthma

Allergies

Medications

Chemicals

Foods

Plants

Digestion

Heartburn

Abdominal Pain

Gas/Bloating

Diarrhea

Constipation

Blood in stool

History of ulcers

Colitis

Liver disease

Skin

Rash

Eczema

Dry skin

Acne

Recent botox

Any recent substance or injection under skin

Eyes/Ears/Mouth

Headaches

Dizziness

Ringing in ears

Blurred vision

Sinus problems

Difficulty swallowing

Mouth sores

Female

Pregnant

Problems with periods

Cancer

Breast tenderness

Breast implants

Menopausal symptoms

Structural

Arthritis

Bursitis

Osteoporosis

Blood clots/ Phlebitis

Foot/Ankle swelling

Varicose veins

Recent surgery

Neck pain/problems

Sciatica

Immune

Chronic fatigue

Fibromyalgia

Yeast infections

Past viral infections

Past strep or mono

Epstein-Barr

Lyme

Male

Prostate

Cancer

Neurologic

Numbness or tingling

Weakness

Insomnia

Poor balance