Client:                                                                            Date:
Patient:                                                                         Since:
Address physical:
Address mailing:
City/State/Zip
Phone (Home)
Phone (Alt.)
e-mail:
Best way to reach you:
How did you hear about us?
DOB:
Male/Female:  Surgeries/Problems/HRT? ______________________
Species/Breed or
Color/Nationalities
Blood Type:   Type O    Type A    Type AB    Type B
How do you best learn?
Do you like working in outlines or details?
Left handed or Right handed?
Religion:
Who is on your team of healers?
1
2
3
4
5
TYN’s Sent:
Date:
Weight:
Heart Rate:
Blood Pressure:
Bowel Movements/day:
Hours Sleep/night:
Low Energy Times:
Daily Water Consumption/Type:
Raw Fruits eaten/day (1/2 cup servings)
Raw Vegetables eaten/day (1/2 cup servings)
Cooked Vegetables eaten/day (1/2 cup servings)
Exercise Type/duration/times per week:
Baths/Showers per week
Allergies:
Job History:
Hobbies:
Places you have lived or traveled to:
Miscellaneous Notes:
Dr. Denice Moffat (208) 877-1222      1069 Elk Meadow Lane  Deary, ID 83823  U.S.A
Form Updated 4/26/11