Intake Form

InExternal Wellness

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InExternal Wellness Intake

Please fill out this form by placing an x in front of all conditions that apply. Hit the submit button when done.

Name: Date: Birthdate: Mailing Address: Primary Phone Number: Emergency Phone Number: EMail Address: The following information will be kept confidential, and is needed to ensure that all of your needs are addressed correctly with Lymphatic and Cold Laser Therapy. Please include any condition that is currently applicable. Thank you. _Acne _Epilepsy _Ovarian Cysts _Allergies _Eczema _Pacemaker _Allergies Pollen _Fever _Parkinson's _Allergies Dust _Fibromyalgia _Psoriasis _Allergies Perfume _Heart condition _Rosacea _Alzheimer's _Hepatitis _Scar Tissue _Arthritis Ostero _High Blood Pressure_Sciatica _Arthritis Rheumatoid _Hormone Replacement_Shingles _Asthma _Hysterectomy _Skin Disorder _Back/Neck Pain _Irritable Bowel _Sunburn _Chronic Fatigue _Insomnia _Thrombosis _Constipation _Low Blood Pressure _Thyroid Problem _Cold Sores/Herpes _Metal Pins/Plates _TMJ _Contagious disease _Menopause Symptoms _Uterine Fibroid _Cystic Breasts _Migrains _Ulcer _Diabetes _Multiple Sclerosis _Varicose Veins Other Health conditions/Surgeries: Cancer: Prescription Medication: Cigarettes: Alcohol: Caffeine: Vitamins/Herbs/Homeopathics: Do you exercise? Pregnant/trying to become pregnant/recently given birth? I CONFIRM THAT TO THE BEST OF MY KNOWLEDGE THE ABOVE IS CORRECT, AND I HAVE NOT WITHHELD ANY INFORMATION RELEVANT TO MY HEALTH. Signature:

Copyright . Kristina Koebel, InExternal Wellness. All rights reserved.