Clients / Patients’ Assessment Form Today’s Date Date Of Birth Age Full Legal Name Social Security # Home phone Cell phone Blood Type E-Mail Current Postal Address Profession/Occupation Current Marital Status Daily Physical Exercise Emergency Contact Person and Phone Number Health/Medical History Allergies and intolerances(Food, chemicals, drugs, vitamins, materials, etc.) Family Health/Medical History Health/Medical History of Spouse (if applicable) Social/Emotional History Familial and Personal Relationship History Diet History Herbal and Vitamin Supplements Current Medications Present Problems/Concerns Duration Signs and Symptoms Treatment Attempted Previously 6 + 12 = Submit
