Neuropathy & Neurotherapy Center of Dallas

12870 Hillcrest Rd, Suite 201, Dallas, TX 75230 (972) 991-6731

PATIENT NAME: *

AGE: *

PERTINENT NEURAL THERAPY HISTORY

What is the reason for our visit today? *

If due to an injury, what is the date of the injury? *

Are you allergic to any medication? (If yes, please list them) *

Please list all the current medications you are taking and strength (if you know it): *

Would you be interested in natural treatments for preventing illness/improving overall health? *

Yes

Do you have difficulty focusing or paying attention? *

Yes

Please complete the following with the approximate age of occurrence:

Other Scars? *

Injuries/Accidents without Stitches: Age: *

With Stitches: *

Toxic Profession - Past or Present (i.e., artist, graphic designer, dentist, gas station worker, painter, etc.) *

Major Psychological Trauma: *

Long periods on prescription or street drugs, alcohol, or cigarettes: *

Serious Infections/Diseases: *

Childhood Vaccinations? *

Yes

Dental Interventions: (i.e., cleanings, fillings): *

PATIENT'S SIGNATURE *

clear

DATE OF SIGNATURE * +