New Client Health History Form For questions related to session billing, please contact the QT Office Manager, Cheryl. Office: 928-771-1215 Toll free US: 888-767-8002 Email: Cheryl@quantumtechniques.com Step 3/3 Please enable JavaScript in your browser to complete this form.Name *FirstLastPhone Number *Email *Practitioner of Choice *Dr. Stephen P. Daniel, Ph.D, FPPRJody King Colegrove, ACP-EFTDr. David KirkpatrickJJ CurrenJamie Daniel-DelgadoClay WardOtherSeverity of ProblemMildModerateSevereUrgently SevereAre You A New Or Returning Client?New ClientReturning ClientDescribe 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?YesNoIf 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?YesNoHave you or your parents ever used accutane for acne?YesNoDo you have white spots on your fingernails?YesNoHave you had a flu shot recently?YesNoHave 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?YesNoDo you have major scars on your body?YesNoDo you have body piercings?YesNoLocation of Piercing(s):Do you have tattoos?YesNoDo you use tobacco?YesNoWhat type of cookware do you use?Stainless SteelAluminumIronTeflon CoatedGlass / CeramicOtherDo you live or work within one-half mile of a cell phone tower?YesNoHow 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 FoodsWhat percentage of your diet is organic?0%25%50%75%100%Please list the most common foods you ingest:LunchDinnerSnacksDo you consume sugar of any kind (white sugar, raw sugar, fructose, honey, maple syrup, etc.)? *YesNoDo you consume artificial sweeteners (like Nutrasweet, Splenda, etc.)? *YesNoPure 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:JuiceSodaSoft DrinksMilkCoffeTeaAlcoholSupplements - Please list any vitamins, minerals, etc. including brand and dosage taken:Personal Care Products - Brand NamesShampooConditionerDetanglerHairspray / Hair GelHair Dye / HighlightAntiperspirant / DeodorantShave CreamPerfume / CologneMake-up / Make-up RemoverNail Polish / RemoverMouthwashToothpasteFlossWhitening ProductsHand Soap / Hand SanitizerSunscreenBug SprayEssential OilsHousehold Products - Brand NamesAll Purpose CleanerGlass CleanerDishwashing SoapDishwashing Detergent Floor CleanerLaundry DetergentLaundry Stain RemoverFabric SoftenerDryer SheetsDo you use any of the following:Air FreshenersCandlesWood In Your FireplaceDo you send clothes out to be dry cleaned?YesNoAdditional - Type / Brand Names Pet ShampooTic / Flea RepellentLawn Fertilizer / PesticideJewelry (Gold, Silver, Etc)New Paint, New Floor Tile / Carpet, Construction of Any KindCooking Source (electric, natural gas, propane, etc.)SubmitSave 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 * Send Link
