HEALTH INTAKE FORM

Name *

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Health outcomes you want to achieve? *

Full reversal of disease.

Get off some or all medications.

Prevent an upcoming scheduled surgery.

Health issue prevention.

Stop the progression of the illness.

More energy.

Better sleep

Others, etc.

Exercise. How many times in an average week do you engage in physical activity? Light activity (housework, gardening, gentle walking) Moderate activity (brisk walking, cycling) Strenuous activity (running, jogging, sports). *

0-3 hours a week

4-6 hours a week

7 or more hours a week

Toxin or Chemical Exposure. Indicate if you have had chronic exposure to toxins, chemicals or alcohol during your life. *

Agricultural

Industrial/Workplace

Alcohol

Cigarettes

Recreational Drugs

Others

Date of Diagnosis.

MM

DD

YYYY