| 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 | ||||