New Client Form for Dr. Alix Bjorklund - Qi Inc

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Personal Information:

City*

Email Address

Birth Date Sex Height Weight

Emergency Contact Emergency Contact Phone Number

Name of Employer Deductible Calendar or Fiscal Year

Whom may we thank for reffering you?

Major complaints:

Major complaints
Other complaints

Date of onset of chief complaint Pain is: How long have you had this condition?

Have you had this in the past? When? What makes it better?

What makes it worse? Is your condition getting:

 

Please Fax or bring in latest blood work and labs

THANK YOU FOR COMPLETING THIS FORM