New Client Intake Form Name * First Name Last Name Email * Phone (###) ### #### Date of Birth MM DD YYYY Your Address Address 1 Address 2 City State/Province Zip/Postal Code Country Gender Male Female Your Occupation Referred by: Emergency Contact: Name & Phone Number Health Concerns please list in order of importance Do you use: Alcohol Tobacco Homeopathics Herbs Are you seeing your Physician for this problem? Yes No Are you seeing Chiropractor Physical Therapist Psychiatrist Are you on a special diet? If so please describe. Are you a vegetarian? Yes No Significant Health History: Including past surgeries, accidents, injuries, diagnoses and family history. Allergies Medication, food, environmental. Please list all drugs and medications you are currently taking Please list all herbs, minerals, vitamins, and supplements you are currently taking: Please check all symptoms that you are concerned about: poor appetite weight gain weight loss fever/chills excess sweating fatigue eye trouble ringing of ears nose bleeds nasal discomfort throat discomfort gum symptoms cough sputum bloody sputum wheezing chest pains heart palpitations shortness of breath swollen feet or ankles leg pains vericose veins jaundice heartburn special food intolerance abdominal pain swollen glands nausea vomiting belching or flatulence rectal discomfort diarrhea constipation backache arthritis or joint pain bursitis muscular aches burning on urination frequency of urination difficult urination night time urination loss of control of urination blood in urine bruise or bleed easily hot weather intolerance cold weather intolerance increased urine volume skin problems hair or nail problems itching headaches dizziness fainting tremor muscle weakness seizures, convulsions faulty memory depression nervousness trouble sleeping work or family problems sexual problems anxiety phobias For Men Only: weak urine stream prostate trouble discharge from penis painful or swollen testes For Women Only menstrual trouble vaginal discharges hot flashes breast lump or discharge For WOMEN Only: Date of Last Period For WOMEN Only: # of pregnancies For WOMEN Only: # of miscarriages For WOMEN Only: # of abortions Place A Check Before Any Illness You Have Had: heart murmur rheumatic fever heart attack or angina other heart disease high blood pressure blood transfusion pneumonia, pleurisy HIV emphysema allergies bleeding disorder jaundice hepatitis ulcer arthritis bulimia anorexia phlebitis thyroid trouble venereal disease tumor cancer diabetes nervous disorder glaucoma gout kidney or gall stones kidney or bladder trouble hernia epilepsy chronic fatigue syndrome Fees Initial 90 minutes appointment fee: $300 (30 minutes consulation fee: $100, and 60 minutes Tui Na fee: $200). Customized herbal extract formula ( capsule or powder form): $320/30 days formula Note: If a patient or client is not satisfied with their initial visit, they don't have to pay for the initial consultation and initial Tui Na service. After the initial visit, if you are happy to pay for our services, we can not offer any refund afterwards. We only service patients and clients who are happy with our service, because we can not guarantee anything for tomorrow. Tomorrow is a mystery, and today is a gift. We believe in the power of now, where everything is in your hand. Appointment & Cancellations By filling out this new patient intake form you agree to opt in to receive contact from us via call, text or email concerning your appointment. We understand that circumstances occasionally arise that will change your plans. You may cancel at no charge if you call at least 24 hrs. before your appointment. If you do not cancel or fail to come for your appointment, a fee of $50.00 will be charged. If you make up your apt. within a week your fee will be waived. Disclaimer This modality known as “Qi Gong Tui Na Therapy, Quantum Energy Medicine” is an ongoing study, being followed by the Taoist Institute of TCM. The practice of energy therapy has never been adequately researched and/or tested in the United States by modern scientific methods. As such, no guarantees or promises as to results and/or to the effectiveness of this modality are offered or implied. This modality is considered to be experimental and in no way should take the place of traditional medical consultation or care. I have read and understand these guidelines and agree to the terms therein. I give permission to receive email and phone call or text from Khufu Healing. Client Signature (or legal guardian if patient is a minor) Today's Date MM DD YYYY Thank you for completing the new patient intake form. We will be in touch with you soon.
