Intake Forms

Please COMPLETELY fill out and submit the Client Health Questionnaire form below 24 hours before your Appointment with ANY of the Modalities*

**Please also COMPLETELY fill out the HOCATT™ specific intake form below and submit if you are making an appointment to use the HOCATT™ for the first time**

**( Completely filling out the intake forms will help us to best prepare for your scheduled appointment and save you time having to finish completing the form in the office.)

What to expect for your HOCATT™ Therapy Session

Please call to schedule an appointment: 480-594-5052

Client Health Questionnaire

Personal Information:

Full Name

Date

Email Address

Cell Phone

Home Phone

Work Phone

Address

City

State

Zip

Date of Bith

Occupation

Emergency Contact

Relationship

Phone

Marital Status: Maried Single

Height

Weight

Sex: Male Female

Physicians

Primary Care:

Phone:

Address:

City:

State:

Zip:

Specialist:

Phone:

Address:

City:

State:

Zip:

State

Health Questions:

1. How did you find Natural Pain Treatment and Wellness? Referral - Friend - Website - Newspaper - Advertisement – Other If referral or friend, please identify.

2. Have you had alternative health therapies before? Yes No

If yes, please identify

3. Which therapies are you currently using?

4. How have these therapies helped you?

Medical History

5. Are you currently under medical supervision? Yes No

If yes, please explain

6. Are you currently taking any medications? Yes No

If yes, please list below

Please explain the conditions that you have marked above:

8. Do you have any implanted electrical devices such as a pacemaker, cochlear implant, intrathecal pump, insulin pump, etc…? Yes No

If yes please list:

9. Do you have any implanted metals such as joint replacements, dental implants, mechanical heart valves, metal stents or metal staples in blood vessels? Yes No

If yes please list:

10. Do you have breast implants or organ transplants? Yes No

11. Do you take immune suppression medications? Yes No

12. Do you have hypotension? Yes No

13. Do you have Graves' Disease? Yes No

Do you have Epilepsy? Yes No

15. Are you pregnant? Yes No

16. Have you had any surgeries? Yes No

If yes, please identify the type and date of each surgery:

18. Is there anything else about your health history that you'd like to mention:

TESTIMONIALS

The content of this Digital Publication, such as text, graphics, images, and other material has not been evaluated by the FDA and is for informational purposes only. The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read, heard or seen on this digital publication. If you schedule an appointment with Natural Pain Treatment and Wellness you will be given natural therapies to support your healing, but they are not a substitute for medical treatment.

* Natural Pain Treatment and Wellness is a PMA . A PMA (Private Membership Association ) is a group of individuals collectively protecting their rights to determine what devices, products, procedures, or services will be used by them to maintain the health of their own body, mind or spirit as guaranteed by the 1st, 4th,5th and 14th Ammendment rights.

480-594-5052