Form

Name*

First Name Middle Name Last Name

AGE*

Preferred Name or Nickname

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Birth Date

Month Day Year

Home Phone

- Area Code Phone Number

Cell Phone

- Area Code Phone Number

E-Mail

Health Provider Name and Phone

Do you use tobacco in any form?

Yes No

If yes, please list type , amount and frequency of use

Do you use Alcohol in any form?

Yes No

If yes, please list type, amount and frequency of use

Are you taking any medication or drugs? If yes, please list medication and doage per day

Please check all problems which you are experiencing or have a history of

	Yes
Abnormal Bleeding
Active Infection
Agoraphobia
Alcohol Abuse
Allergies
Alzheimer's
Anemia
Anxiety
Arthritis
Asthma
Back Pain
Bone/Joint Disease
Blood Transfusion
Blood Clots
Broken/Fractured Bones
Cancer
Cardiac Condition
Chronic/Acute Fatique
Chronic/Acute Pain
Circulatory Condition
Confusion
Cold
Diabetes
Depression
Difficulty Breathing
Drug Abuse
Emphysema
Epilepsy
Facial Surgery
Fainting Spells
Flu
Forgetfulness
Glaucoma
Heart Problems
Headaches
HIV + AIDS
Heart Attack
Heart Surgery
Hepatitis
High Blood Pressure
Joint Pain/Replacement
Kidney Problems
Limited Mobility
Liver Disease
Low Blood Pressure
Multiple Sclerosis
Osteoporosis
Overweight
Pacemaker
Pregnancy
Pressure Sores
Psychiatric Care
Radiation Therapy
Respiratory Condition
Rheumatic Fever
Shortness of Breath
Sprains/Strains
Seizures
Shingles
Sickle Cell Disease
Sinus Problems
Skin Wounds/Lesions
Spasms/Cramps
Stroke
Thyroid
Tuberculosis
Ulcers
Varicose Veins
Vascular Condition

Additional Physical/Mental Health Conditions

Recent Surgeries or Medical Procedures

Have you received treatments similar to what we offer?

Yes No Some

If so, please list type and frequency

Emergency Contact Person

First Name Last Name

Emergency Contact Phone

- Area Code Phone Number

I, the undersigned, certify that I (or my dependent) will be responsible for payment for services rendered. I understand that the information which I have provided on this form is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform the staff of Body Mind ReNew of any changes in my medical status. I will immediately notify the Body Mind Renew of any pain or discomfort during the treatment. I affirm that I have stated all known medical conditions, and answered all questions honestly. I agree to inform Body Mind ReNew of any changes in my health status, and I understand that there shall be no liability against Body Mind ReNew for my failure to do so.I waive and release any and all claims for damages that I may have against Body Mind ReNew, its owners, staff, associates, attendants, and affiliates. I agree to hold Body Mind ReNew harmless and indemnify it for any incident(s) which may arise, past, present, or future, from my use of services provided by Body Mind ReNew."

I have read and understand the following statements: Always consult your physician before considering alternative treatment therapy. Some ailments and conditions may be contraindications for receiving alternative treatment therapy. Treatments provided by Body Mind ReNew should not be construed as a substitute for medical examination, diagnosis, or medical cures, and you should seek a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which you are aware.

I have read and understood the form in its entirety. By entering my first and last name, and clicking the submit button on this Form I am indicating that I have read, agree to, and understand this form.

How may we help you today?

Your current overall state of health is

Good Fair Poor

Is there any specific service and/or concern you would like to inquire about?

What date/time would you like to schedule your initial consultation or treatment?

/ Month / Day Year

at

: Hour Minutes

Full Name*

First Name Last Name

Body Mind ReNew-Health History Form

Medical History

Assignment and Release