New Clients History Form

Client History Fillable Form

  • This is a long form, but only the items marked with a star are required . 🙂
  • if both parents do not share same address, please see below for opportunity to provide second address.
  • Please mention when this may have first started; what makes it better or worse. Please list as many details as you wish.
  • Antibiotics, AntiVirals, Heart Medications, Chemo Therapy, Anti Inflammatories, Birth ControlOver the counter taken regularlyOver the counter taken ocassionally 
    Add a new row
    You may add up to 50 medications, vitamins or recreational drugs.. Hit the plus sign to the right of the first empty field to add each.
  • Drop files here or
    Accepted file types: jpdf, png, jpg, jpeg, doc, docx.
    If you prefer to send these by email or bring them to your appointment you are welcome to do so. email: Lise@lisebattaglia.com
  • Drop files here or
    Accepted file types: pdf, png, jpg, jpeg, doc, docx.
    If the client was born after 1973, this information may prove to be very helpful in selecting the most appropriate remedy. If you do not have it, the pediatrician or school may have it. They are legally obligated to give it to you upon request
  • grandparents on mother's sideIllness/cause of deathgrandparents on father's sideIllness/cause of death 
    Add a new row
    You may add up to 8 family members on both the paternal and maternal side of the family. Hit the plus sign to the right of the first empty field to add names
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