SHC Client Form

Date of Appointment

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Full Name

First Name Last Name
Who were you referred by?
Email
Phone Number

Area Code Phone Number

Address

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

Date

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Height
Weight (lbs)
Age (Years)
Date of Birth

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Marital Status

Single Married
Do you have children

Yes No
Occupation
Family Health History
Mother
Father
Brother
Sister
Your Health History
Check all that apply

Anger Anorexia Anxiety Appendicitis Arthritis Asthma Back Pain (Lower) Bad Breath Bladder / Urinary Disorders Blood Pressure (High) Blood Pressure (Low) Blood Shot Eyes Bottle-Fed Breast-Fed Bulimia C-Section Birth Calf Cramps (during the night) Canker Sores Cavities (multiple) Carbohydrate or sweet cravings Chronic Fatigue Cold Extremities Constipation Diabetes Diarrhea Dizziness Dry Skin Excess Phlegm and Mucus Excessive Colds & Flu Fear Gas Hair thinning/loss (female) Headaches Heartburn Heavy/Dull Feeling Hemorrhoids Hepatitis Hot Flashes Hunger (Excess) Hyperacidity Hyperthyroid Hypothyroid Inability to Concentrate Indigestion Inflammation Insomnia Intolerance to Heat Intolerant to Cold/Damp Memory Issues Menopauses Menstrual Cramps (Bad) Muscle Stiffness Neck, shoulder or back spasms Overweight Pain (muscle) Period (Heavy) PMS Restless Ringing in Ears Seasonal Allergies Sinus Congestion Skin Rashes Sleeping (Excessive) Sleeping Trouble (fall asleep, wake up multiple times) Sleeping Trouble (trouble falling asleep, racing mind) Sore Throat Ulcers Vaginal Birth Yeast
What is Your History of Antibiotic Use?
Fasting Glucose
Testosterone (Men)
Vitamin D Level
Thyroid Reading
T3
T4
TSH
Food/Environmental Allergies or Sensitivities
What foods do you dislike?
Number of alcoholic drinks per week
Number of cups of coffee per day
Number of sodas per day
Number of glasses of water per day
Exercise pattern per week

0 days 1-3 days 3-5 days 5-7 days
Type(s) of Exercise
Stress level at work from 1-10 (10 is the highest)
Stress level at home from 1-10 (10 is the highest)
List any supplementation you take including brand name, type and amount.
Do you take any medication? If so, please list.
Do you have cancer?

Yes No
If you have cancer, please give the specific type (i.e. ER positive breast cancer). If you are doing chemotherapy, please give the specific drug used.
Please describe in detail any significant health changes or surgeries you have had in the last 10 years.
What is your goal for the appointment today?
Should be Empty:

Family Health History

Your Health History

Thyroid Reading