Total Health Patient Consultation

Have you ever had OR will you have a stem cell treatment?*

Yes
No

New Patient Appointment Date:*

Time*

: HH

MM

Today’s Date*

Patient’s Information

Name*

Prefer to be called*

Spouse/Partner

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone*

Work Phone

E-mail Address*

Birth Date*

Age*

Gender:*

Male
Female

Marital Status*

General Information

Do you have a Primary Care Doctor?*

Yes
No

Physician’s name:

Physician’s Contact Number:

Have you consulted a doctor about your current condition(s)?

Yes
No

Please state diagnosis, therapy and the results:

Account Information

Person responsible for the account*

Occupation

Employer

Business Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Business Phone

Person to Contact in Case of Emergency

Name*

Relationship*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone*

Step 1 of 12

Patient’s Information

General Information

Account Information

Person to Contact in Case of Emergency

Authorization for Treatment

Personal History

Current Health Condition

Family Medical History

Family members affected

Medications and Hospitalizations

Allergies

Health Data

Health History

Hormone Medication History

Personal Health Habits

Occupational and Household Exposure

Detoxification

Digestion and Eating Habits

Skin

Life Style Index

Vitality Survey

Women Only

Female Hormone Imbalance Rating

Men Only

Male Hormone Imbalance Rating