KIM BARZILAY, NHC VEGA TESTING - INTAKE FORM
CLIENT NAME:______________________________________________________ DATE:______________________
Parent/guardian name (if child):_________________________________
Signature of parent/guardian:______________________
Address:_____________________________________________________________________
Postal Code:____________
Phone Number/ Cell:______________________________ Text: Y / N Home/Work:____________________________
Email:_________________________________________________________ I would like to receive a newsletter: Y / N
Birth year:___________________ Gender: _________ prefer not to answer___________
OCCUPATION:______________________________________________________________________________________
FAMILY PHYSICIAN:________________________________________________________________________________
All information is confidential. Answer only what you wish to reveal in your health assessment. Use back of form if needed.
Medical History:
What brings you to my office?_________________________________________________________________________________________
Are you currently under treatment with any other health practitioner? Y / N
LIST:________________________________________________________________________________________________________________________________________________________________________________
Are you on any medications from your doctor or any drug store products? Y / N
LIST:________________________________________________________________________________________________________________________________________________________________________________
Are you taking supplements: Y / N
LIST:________________________________________________________________________________________________________________________________________________________________________________
Do you have a pacemaker: Y / N Are you pregnant: Y / N
Do you have any known allergies: Y / N
LIST:______________________________________________________________________________________
How do you react:_____________________________________________________________________________________
How would you rate your stress: None / Slight / Moderate / Severe
What are your health goals______________________________________________________________________________________
How did you hear of my service: Family / Friend / Newspaper / Facebook / Website / Referral Who:____________________________
The Vega Test is not intended as a replacement for standard methods of evaluation, but as a complimentary tool to help assess any imbalances in your body. This tool does not eliminate the necessity and effectiveness for a physician’s exam, blood tests, x-rays, or other diagnostic means. The information obtained from the Vega Test is a piece of your overall health picture. Thank you for your time.
SIGNATURE:_______________________________________________________________________________
CLIENT NAME:______________________________________________________ DATE:______________________
Parent/guardian name (if child):_________________________________
Signature of parent/guardian:______________________
Address:_____________________________________________________________________
Postal Code:____________
Phone Number/ Cell:______________________________ Text: Y / N Home/Work:____________________________
Email:_________________________________________________________ I would like to receive a newsletter: Y / N
Birth year:___________________ Gender: _________ prefer not to answer___________
OCCUPATION:______________________________________________________________________________________
FAMILY PHYSICIAN:________________________________________________________________________________
All information is confidential. Answer only what you wish to reveal in your health assessment. Use back of form if needed.
Medical History:
What brings you to my office?_________________________________________________________________________________________
Are you currently under treatment with any other health practitioner? Y / N
LIST:________________________________________________________________________________________________________________________________________________________________________________
Are you on any medications from your doctor or any drug store products? Y / N
LIST:________________________________________________________________________________________________________________________________________________________________________________
Are you taking supplements: Y / N
LIST:________________________________________________________________________________________________________________________________________________________________________________
Do you have a pacemaker: Y / N Are you pregnant: Y / N
Do you have any known allergies: Y / N
LIST:______________________________________________________________________________________
How do you react:_____________________________________________________________________________________
How would you rate your stress: None / Slight / Moderate / Severe
What are your health goals______________________________________________________________________________________
How did you hear of my service: Family / Friend / Newspaper / Facebook / Website / Referral Who:____________________________
The Vega Test is not intended as a replacement for standard methods of evaluation, but as a complimentary tool to help assess any imbalances in your body. This tool does not eliminate the necessity and effectiveness for a physician’s exam, blood tests, x-rays, or other diagnostic means. The information obtained from the Vega Test is a piece of your overall health picture. Thank you for your time.
SIGNATURE:_______________________________________________________________________________
