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New Client Health History Form

For questions related to session billing, please contact the QT Business Manager, Jamie.

Office: 360-913-3764
Email: jamie@quantumtechnqies.com

Step 3/3

Name *

First

Last

Phone Number *

Email *

Practitioner of Choice *

Dr. Stephen P. Daniel, Ph.D, FPPR
Jody King Colegrove, ACP-EFT
Dr. David Kirkpatrick
JJ Curren
Jamie Daniel-Delgado
Clay Ward
Other

Severity of Problem

Mild
Moderate
Severe
Urgently Severe

Are You A New Or Returning Client?

New Client
Returning Client

Describe the issue(s) you want assistance in healing:

Please list any medications taken now or in the past:

Treatment history: What remedies and treatments have you tried? What helped?

List any personal or family history of allergies, asthma, headaches, bowel problems, or other illnesses. (These are frequently associated with food and environmental allergens).

Have you ever had a bad reaction to a medication/drug, herb, or supplement? If so, identify the product and describe your adverse reaction.

Have you every had any severe reaction to anything including food, lotions, herbs, pesticides, chemicals, etc, especially if the reaction involved hives or something on the skin? (Please provide substance and reaction details.) (copy)

Have You Had COVID?

Yes
No

If so, how many times have you had COVID?

If yes, when did you have COVID and how sever were your symptoms?

If yes, how were you diagnosed? (rapid test / office visit / self diagnosed)

Did you receive a COVID vaccine? If so, which brand?

Did you receive any COVID booster shots? If so, how many?

Did you experience any adverse reactions to the vaccine?

Since you had covid/vaccination(s) have you had any new or increased symptoms of illness? If so, please describe.

Have you ever been bitten by a tick and or had lymes?

Yes
No

Have you or your parents ever used accutane for acne?

Yes
No

Do you have white spots on your fingernails?

Yes
No

Have you had a flu shot recently?

Yes
No

Have you ever had a traumatic or poor response to a surgery? If so, describe the purpose of the surgery and indicate when it occurred.

Conditions, places, circumstances and instances that evoke the current problem:

Please list any man-made objects in your body and the date of the surgery; for example, stents, pins, artificial joints, root canals, crowns, pacemakers, etc.

What surgeries, operations, traumas, accidents, etc., have you had?

Have you ever had a head or tailbone injury?

Yes
No

Do you have major scars on your body?

Yes
No

Do you have body piercings?

Yes
No

Location of Piercing(s):

Do you have tattoos?

Yes
No

Do you use tobacco?

Yes
No

What type of cookware do you use?

Do you live or work within one-half mile of a cell phone tower?

Yes
No

How many hours of sleep do you average every night?

Is there anything else you want to tell us-that will allow us to more completely help you?

Typical Foods

What percentage of your diet is organic?

0%
25%
50%
75%
100%

Please list the most common foods you ingest:

Lunch

Dinner

Snacks

Do you consume sugar of any kind (white sugar, raw sugar, fructose, honey, maple syrup, etc.)? *

Yes
No

Do you consume artificial sweeteners (like Nutrasweet, Splenda, etc.)? *

Yes
No

Pure Water Consumption (no lemon, no additives, just water) Indicate the total number of cups you drink each day:

Caffeine Consumption (Including any coffee, any tea, AND decaffinated as well) Provide the total number of cups consumed each day:

Beverage Types and Amounts:

Juice

Soda

Soft Drinks

Milk

Coffe

Tea

Alcohol

Supplements - Please list any vitamins, minerals, etc. including brand and dosage taken:

Personal Care Products - Brand Names

Shampoo

Conditioner

Detangler

Hairspray / Hair Gel

Hair Dye / Highlight

Antiperspirant / Deodorant

Shave Cream

Perfume / Cologne

Make-up / Make-up Remover

Nail Polish / Remover

Mouthwash

Toothpaste

Floss

Whitening Products

Hand Soap / Hand Sanitizer

Sunscreen

Bug Spray

Essential Oils

Household Products - Brand Names

All Purpose Cleaner

Glass Cleaner

Dishwashing Soap

Dishwashing Detergent

Floor Cleaner

Laundry Detergent

Laundry Stain Remover

Fabric Softener

Dryer Sheets

Do you use any of the following:

Air Fresheners
Candles
Wood In Your Fireplace

Do you send clothes out to be dry cleaned?

Yes
No

Additional - Type / Brand Names

Pet Shampoo

Tic / Flea Repellent

Lawn Fertilizer / Pesticide

Jewelry (Gold, Silver, Etc)

New Paint, New Floor Tile / Carpet, Construction of Any Kind

Cooking Source (electric, natural gas, propane, etc.)

Save and Resume Later

Your form entry has been saved and a unique link has been created which you can access to resume this form.

Enter your email address to receive the link via email. Alternatively, you can copy and save the link below.

Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted.

Copy Link

Email *

Quantum Techniques

*Quantum Techniques (QT) is not intended to diagnose, prescribe, treat, or cure any disease, physical or mental. The use of Quantum Techniques by a Quantum Techniques practitioner should not be construed as a prescription, a promise of benefits, claims of cures, or a guarantee of results to be achieved. Full disclaimer here.

© Quantum Techniques 2026 – All Rights Reserved

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