Do you see any other healthcare providers? If so, please list their information below.
If you have a current health condition, or have been diagnosed with one in the past, please list below (eg. diabetes, cancer, IBS etc...)
Please indicate if you have had any of the following concerns in the past year, or of significance in the past.
Please indicate if any of your family members currently have a health condition, or have had one in the past
Please describe a typical day's diet
Please quickly rate your level of satisfaction with the following areas of your life.(1 star = not satisfied, 5 star = very satisfied)
I, the undersigned person(s), do agree and understand that the practioners of Rivers Edge Natural Health are NOT medical doctors, chiropractors, registered nurses, licensed practical nurses, licensed physical therapist/physio-therapists or licensed counselors. I understand and agree that they only claim to be, respectfully, a Doctor of Naturopathic Medicine, Certified Natural Health Practioners (CNHP's), a DieteticTechnician Registered (DTR), a Christian Family Preservation Child/Family Advocate and Ordained Ministers.
I affirm that I have come to this agency to avail myself of the respected servcies offered and have not, nor will I ask these practitioners to do anything illegal, nor anything that is against the practioner's personal or professional values and/or ethics. Further, I release them from any and all liability arising out of claims or matters that relate, in whole or in part, to my sessions with Rivers Edge Practioners.
Thanks for taking the time to complete this intake form and We look forward to meeting you!