Health Intake

Health Intake

  • Date Format: MM slash DD slash YYYY
  • If under the age of 18

  • Nutritonal Data

  • Movement

  • Sleep

  • Eliminations

  • Emotions

  • Females

  • Supplements/medications

  • Medical history

  • Naturopathic History

  • Drop files here or
    I understand that I am here to learn about lifestyle and better health practices, that I will be offered information about food supplements and herbs as a guide to general good health, and this is a personal ministry and spiritual counseling. I fully understand that those who counsel me are not medical doctors and I am not here for medical diagnostic purpose or treatment procedures. I am not on this visit, or any subsequent visit, an agent for federal, state or local agencies or on a mission of entrapment or investigation. The services performed here are at all times restricted to consultation on holistic wellness matters intended for the maintenance of the best possible state of natural health, and do not involve the diagnosing, treatment or prescribing of remedies for disease.