Goodman Wellness
Joan L. Goodman, CTN, MH
Certified Traditional Naturopath
11807 Westheimer Suite 550-353
Houston, TX 77077
281-493-9473
Instructions
Whether you’re an existing client or a new client, please submit the
following prior to your next appointment if you haven’t already done so.
________________________________________________
You may choose to email your Client Forms and Tests
to joan@goodmanwellness.com
OR
Mail all to: Address above
Client Packet Forms- Please carefully and thoughtfully fill all the attached forms providing
as many details as possible. Take your time!
Photo - Send a small recent photo of ONLY yourself.
Tests - Send copies of any lab tests, medical reports, or blood work done in the last six
months.
Biologicals – In a small envelope, place:
1. 1 Fingernail clipping
2. 5 strands of hair - root not necessary and length is irrelevant.
Seal the envelope with your own saliva.
On the outside: a) print your full name b) sign your full name c) write birth date.
Mail this smaller envelope in a larger envelope to ensure it arrives undamaged.
Thank you,
Joan Goodman, CTN
Goodman Wellness
11807 Westheimer Suite 505-353 Houston, TX 77077
281-943-9473 joan@goodmanwellness.com
This is a fillable form. 1. Right mouse click and "save as" the form to your computer. 2. Open it on your computer, place your
cursor in the fields, and type. 3. Sign and save it on your computer 4. Email it as an attachment to the email address above.
(This saves me from having to scan it in.) If you are more comfortable with a printed form, print it, fill it in, and mail it to
above address.
_____________________
_____________________________________________Gender: ___________________
Today's date:
Name
First
Middle
Last
Birth Name_________________________________________________________________________________
Birth Date
____/_____/_____
Birthplace
_____________________
Current Age:
_______ Height: _________
Weight:
_________
Birth Time _____________________
Home Address_____________________________________________________________
City: ________________________
State: ________
Zip:
___________________________
Billing Address_____________________________________________________________
City: ________________________
Phone:
Home: ___________________
State: ________
Zip:
___________________________
_______
Ok to leave message? _______
Work: ___________________
Ok to leave message? _______
Cell: ___________________
__________________________________________________________ __________
Email:
Name of Parents (if patient is a minor): ___________________________________________________
Occupation: _______________________Employer:___________________________________________
Marital Status:
_________________Children: ___________________________________________
Ok to leave message?
Emergency Contact:
#1 Name: _______________________________________
Home Phone: _______________________________________
Business Phone: _________________________________________
#2 Name: _______________________________________
Home Phone: _______________________________________
Business Phone: _________________________________________
Health Information
Relationship: _______________
Relationship: _______________
Present Health Concerns: Please list your most important health concerns, in order of importance to you
( #1 being the most important and #4 the least important).
1)__________________________________________________________________________________
2)__________________________________________________________________________________
3)__________________________________________________________________________________
4)__________________________________________________________________________________
Your Goals for the first consultation:
1)__________________________________________________________________________________
2)__________________________________________________________________________________
3)__________________________________________________________________________________
Last Name: _________________________________________
Goodman Wellness
11807 Westheimer Suite 505-353 Houston, TX 77077
281-943-9473 joan@goodmanwellness.com
Any Specific Questions for today:
1)__________________________________________________________________________________
2)__________________________________________________________________________________
Allergies: Please list all food, environmental, and/or drug allergies:
1)__________________________________________________________________________________
2)__________________________________________________________________________________
3)__________________________________________________________________________________
4)__________________________________________________________________________________
5)__________________________________________________________________________________
Current prescription medications, non-prescription medications, health supplements:
Name of Medication, supplement,
vitamin, herbs
Dose in mg,
grams or #
Tablets
Frequency Exact Time of
day you take it
For what symptoms and for how long have you been taking it?
Last Name: _________________________________________
Goodman Wellness
11807 Westheimer Suite 505-353 Houston, TX 77077
281-943-9473 joan@goodmanwellness.com
Your last visit to a doctor was____________________ for what reason?_____________________________________
Specialty care physician's name_____________________________________________________________________
Your primary care physician's name__________________________________________________________________
Date of last complete phycial examination:_____________________________________________________________
Date of most recent lab/blood tests__________________________________________________________________
Women:
Date of last pap smear_________
Pregnant currently:
Are you or have you experienced Menopause?
Results: _________________
Yes
Yes
No
No
Unsure
Unsure
Please use the "highlight text" feature in Acrobat to
highlight your answers
Medical procedures, hospitalizations, major injuries, serious illnesses:
Approximate date/year
Details:
Family history of ailments and health issues:
Who
Details:
_____________________________________________________________________________________________
Exercise: Do you exercise regularly? What do you do? If NO - what keeps you from exercising?
____________________________________________________________________________________
____________________________________________________________________________________
Habits and Lifestyle: Please use the "highlight text" feature in Acrobat to highlight any of the following you use:
Tobacco/Cigarettes
Cola/Soda
Alcohol
Caffeine Drinks
Coffee
Recreational Drugs
Spiritual practice:
Last Name: _________________________________________
Goodman Wellness
11807 Westheimer Suite 505-353 Houston, TX 77077
281-943-9473 joan@goodmanwellness.com
Do you follow any type of diet (ie. vegan, vegetarian, kosher…)? Why?
____________________________________________________________________________________
Office Policies:
* Joan Goodman, CTN, MH is a consulting practitioner in complementary health and wellness.
* Joan Goodman, CTN, MH requests that you maintain your primary care physician.
* Payment is due prior to consultation.
* Cancellations require 24-hour advanced notice.
* Cancellations made with less than 24 hours notice will be charged $100 for the missed appointment.
* Insurance - in general - does not recognize naturopathic services.
Complementary means "that which fills up or completes, it is that which is added to make a whole." (Webster's ) The
practitioners and therapists involved are not making any medical diagnosis or medical claim. Our program is a
complementary educational program for wellness that is intended to help you partner with your physician in the care and wellbeing of your own body. When in doubt, always consult your primary care medical physician. In case of emergencies - go to
your nearest medical emergency facility.
I have read and understand the office policies above.
Name:
______________________________________________________
Date: ___________________
Your signature is required for us to proceed with your workup.
Please let me know how you heard of Goodman Wellness: ________________________________________________________________________
Congratulations! You have just taken the first step towards a healthier tomorrow!
Save to your computer then email to: joan@goodmanwellness.com
Or Mail to: Goodman Wellness 11807 Westheimer Suite 505-353 Houston, TX 77077
Last Name: _________________________________________
Goodman Wellness
11807 Westheimer Suite 505-353 Houston, TX 77077
281-943-9473 joan@goodmanwellness.com
PAYMENT INFORMATION:
A credit card and shipping information is required to be on file for
future appointments and supplements.
DATE: ____________
CLIENT NAME: __________________________________________
NAME ON CARD:_________________________________________
CARDHOLDER DATE OF BIRTH: __________
BILLING ADDRESS: ______________________________________
CITY________________
STATE __________
ZIP __________
PHONE: ___________________ CELL: ______________________
EMAIL: __________________________________________________
CREDIT CARD MC/VISA or AMEX? ________________________
CREDIT CARD NUMBER: _________________________________
CVC CODE ___________________
EXPIRATION DATE: ______________________
SHIPPING ADDRESS THE SAME? Y/N
IF NO PLEASE PROVIDE:
__________________________________________________________
__________________________________________________________