The Grecian Garden
New Client Paperwork
Your confidentiality is of utmost importance. This document is sent directly to my in box and saved to your file.
Thoroughly answer questions with * for consideration as a new client.
Height & Weight
Marital Status (S, M, D, W)
Spouse's Name & Description of His/Her Health
Children ( Age & Gender)
(If so, children's physical conditions or concerns.)
Family History of Serious Illness (Cancer, Diabetes, Heart, Other)
Pets or Animals You Have Close Contact With
Your Overall Health Condition (Excellent, Good, Fair, Other)
Main Health Complaint
Previous Treatments for this Complaint
Other Complaints or Problems
Nutritional Supplements You are Taking
Are you currently under the care of a physician or other healthcare professional?
(If so, name and date of last visit.)
Do you smoke, drink coffee or alcohol? How much?
Dietary Intake Two Days Before Appointment (Breakfast, Lunch, Dinner, & Snacks)
Who referred you to The Grecian Garden?*
Thank you for filling out your paperwork. I look forward to seeing you at your next appointment. My office is located inside Old Thyme Remedies at 2475 East Nine Mile Rd, Suite E, Pensacola, Fl 32514.
Oops. An error occurred.
to try again.