New Patient Health History Questionnaire
All information contained in this questionnaire is strictly confidential and will become part of your medical record.
Date of Birth
Health Care Provider
Friend or Family Member
Name(s) of current health care provider(s) (primary and others):
Preferred pharmacy (name, location, phone number):
Reasons for seeking care--What are you hoping to gain from your experience with CCM?
Improve overall health and well-being
Improve energy levels
Reduce specific health risk factors (blood pressure, cholesterol, diabetes, other)
Address weight, body composition concerns, and/or metabolic factors
Improve athletic performance, cardio fitness, and/or strength
Athlete overtraining syndrome evaluation
VO2max or other athlete/fitness testing