Family Medical History: - Ashalee White
Ashalee White’s Energy Therapy Clinic
335 George St.
Sydney NS B1P-1J7
|First Name: Last Name: |
|Address: |
|City: Province: Postal Code: |
|Phone: Male/Female/Other |
|Email: |
|Date of birth: Age: |
|Marital status: Doctor: |
|Emergency contact: Phone: |
|How did you hear about this office? |
*Please describe the main reason for your visit today:
___________________________________________________________
___________________________________________________________
*Please indicate if you have any of the following:
❑ Cardiac pacemaker
❑ Seizure disorder
❑ Bleeding disorder/ Take blood thinners
❑ Fainting disorders
❑ High blood pressure
❑ Believe you are or may be pregnant
❑ HIV/AIDS
❑ Hepatitis
❑ Tuberculosis
❑ Breast Implants
*List all major childhood and adult illnesses:
___________________________________________________________
___________________________________________________________
*If you had any surgeries, major accidents or injuries, please explain:
___________________________________________________________
___________________________________________________________
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*List any major disease or illness in your immediate family and indicate family member:
*List all medications or supplements, including herbs and vitamins you are currently taking:
__________________________________________________________________________________________________________________________________________________________________________________________
*Occupation:
*Do you have a regular exercise program? Please describe.
*Are you on a restricted diet? What kind?
*How many packs of cigarettes do you smoke per week?
*How much coffee, tea, or cola do you drink per week?
*How much alcohol do you drink per week?
*Do you do any drugs? How much per week?
*Indicate painful or distressed areas. Please rate pain on a scale of 1 (No pain) to 10 (Worst pain).
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