Confidential Personal History -- before appointment with Dr. Edythe
We are looking forward to seeing you! Please complete this comprehensive health history questionnaire  before your visit. Dr. Edythe Heus reviews each new patient’s history in detail as part of her evaluation of how to personalize your treatment plan. It would be helpful to know all of your symptoms and health concerns, because these often have related underlying causes which can be addressed during treatment.

Please allow at least 30 Minutes to fill out this form and save your responses.  Some people find it easier to fill this out on their computer or by turning their mobile phone sideways.  All responses will be kept confidential.

If we do not sincerely believe you will respond optimally to our treatment methods, we will not accept your case. Your commitment to your health and fitness figure significantly into our acceptance and help us determine how to serve your health and fitness needs. Please feel free to contact us at info@RevInMo.com if you have any questions.

Thank you,

Dr. Edythe and the RevInMo Team

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Email *
CONTACT INFO
First Name & Last Name *
Who were you referred by? How did you find out about us? (please be specific) *
Address, Street, City, State, Zip (for receiving shipped items) *
Mobile phone *
Other phone (if mobile isn't preferred #)
I consent to being contacted by Voicemail, Text Message, and Email *
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My preferred methods for coordinating appointments are (select all that apply) *
Required
In case of emergency, you have my permission to contact: Name:___   Mobile #:___ Email:___  Relationship:___ *
PAYMENT INFORMATION
Credit card info (number, expiration, security code) *
ABOUT YOU
Date of Birth *
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Sex
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Marital Status (select all that apply)
Spouse/Partner's Name
Number of Children & Ages
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