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New Patient Health History Questionnaire
All information contained in this questionnaire is strictly confidential and will become part of your medical record.
First Name
*
Last Name
*
Date of Birth
*
+
Age
*
Gender
*
Female
Male
Phone Number
*
Email Address
*
Referred by:
*
Health Care Provider
Friend or Family Member
Internet Search
Workshop Attended
Other
Other
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
Fertility concerns
Improve athletic performance, cardio fitness, and/or strength
Athlete overtraining syndrome evaluation
VO2max or other athlete/fitness testing
Other
Other