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Patient Intake Forms

Complete all sections below. Your information is encrypted and handled in accordance with HIPAA privacy standards.

Step 1 of 6

Personal Info & Health History

Personal Information

Please provide your contact and personal details.

Health History

This information helps us provide safe and effective therapy.

Under care of physician in the past year?
Diagnosed with chronic illness?
Do you exercise?
Recent injuries?
Metal or electrical implants?
Demand pacemaker?
Botox injections?
Known allergies?
Allergies to latex or drugs?
Problems sleeping?
Pregnant or breastfeeding?
Epileptic or seizures?
Stroke or hypertension?
Smoke tobacco?

Daily Consumption

Do you take minerals or electrolytes?