Wellness Nashville Client Info
Standard - ver: 10/25/2021
Information Sheet
Name:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Email:
*
Confirmation Email
example@example.com
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social Security Number:
*
Preferred Phone:
*
Please enter a valid phone number.
Alternate Phone:
Please enter a valid phone number.
If unable to reach me:
you may leave a detailed message
you may leave a message asking me to return your call
you may text me
you may email me
The best time to reach me is
day
between
time
.
Do you wish to receive info, promos, and discounts?
*
Yes, please sign me up.
No thanks.
Emergency Contact
Name:
First Name
Last Name
Relationship:
Is contact address the same as above?
Yes
No
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Who referred you to us?
*
Advertisement (Please specify media type)
Another Client (Please specify)
Business or Business associate (Please specify)
Clergy or Church member (Please specify)
Counselor or MH program (Please specify)
Email
Flyer
Friend or Acquaintance (Please specify)
Internet
Other
None
Please describe:
Insurance
Do you have medical insurance?
Yes
No
We now work with most major insurance providers.
Primary Provider:
BCBS
Aetna
Cigna
United Healthcare
Other
Group Policy #:
Individual Policy #:
Secondary Provider:
BCBS
Aetna
Cigna
United Healthcare
Other
Group Policy #:
Individual Policy #:
Gender:
Male
Female
Current living situation:
Married
Single
Divorced
Widowed
Legally Separated
Do you have children living with you?
Yes
No
How Many?
Ages?
Are you currently employed?
Yes
No
Occupation:
What is your main goal in getting NAD therapy?
Do you have a history of heart failure?
Yes
No
Do you have a history of cancer?
Yes
No
What type?
Dates of care:
Last Physical Exam:
By Whom:
Last Mammogram:
Last Colonoscopy:
Height - feet:
Height - inches:
Weight - pounds:
BMI (office use only):
Rank stress over last 3 months:
1=Low
2
3
4
5
6
7
8
9
10=High
Activity level:
Inactive: no regular physical activity with a sit-down job
Light activity: no organized physical activity during leisure time
Moderate activity: occasionally involved in activities such as weekend golf, tennis, jogging, swimming or cycling
Heavy activity: consistent lifting, stair climbing, heavy construction, etc. or regular participation in jogging, swimming, cycling or active sports at least three times per week
Vigorous activity:participation in extensive physical exercise for at least 60 min / session for at least 4 times per week or more
Chemical Use:
Past
Present
How Much
Tobacco
Alcohol
Sleeping pills / Sedatives
Caffeine
Illicit substances
Medical and Family History
Type:
Family
Self
If Self, how long?
Seizures
Migraines
Dementia
Mood disorders
Anxiety disorders
Eating disorders
Sleep disorders
Loss of consciousness
Previous head injury
Stroke
Parkinson's disease
Abnormal cholesterol
High blood pressure
Heart attack / Angina
Irregular heart rhythm
Asthma / COPD
Diabetes / high blood sugar
Thyroid disorder
Obesity
Kidney stones or disease
Liver disease / Hepatitis
Ulcers / Colitis
Arthritis
Gout
Osteopenia / Osteoporosis
HIV
TB
Autoimmune disease
Males persistent or painful erection (Priapism)
Surgeries and Hospitalizations
Reason / Diagnosis, Year:
Review of Systems
Please check YES to any symptom that you experience.
General:
YES
Please describe
Anxiety / nervousness
Food cravings
Memory difficulties
Sadness
Concentration problems
Irritability
Night sweats
Excess fatigue
Weight loss or gain
Enlarged lymph nodes
Ringing in ears
Hearing difficulty
Dizziness
Hair loss
Cardiovascular:
YES
Please describe
Chest pain at rest or exercise
Swelling of feet or legs
Leg pain with walking
Palpitations
Shortness of breath with exertion
Low blood pressure
Gastrointestinal:
YES
Please describe
Abdominal pain
Constipation
Diarrhea
Bloating
Excessive belching / heartburn
Genitourinary:
YES
Please describe
Kidney stones
Musculoskeletal:
YES
Please describe
Back and/or neck pain
Joint pain - shoulder, elbow, knee, hip
Point tenderness - Where? Describe
Allergies, Medications, and Supplements
Allergies to Medications:
Prescription Medications:
Medication Name
Dose &
Frequency
Approx.
Start Date
Reason
for Use
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Supplements and Over-the-Counter Medications:
Medication Name
Dose &
Frequency
Approx.
Start Date
Reason
for Use
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Please verify that you are human:
*
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