intake form Form Preview
  • This is a confidential record of your medical history and will be kept in this office. Information contained in it will not be released to any person unless authorized by you.

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  • Health Concerns

  • Vitamins and Supplements

  • Medications

  • Family History

  • Next to each individual listed below, please put an “L” for living or “D” for deceased, as well as present age or age at the time of death. Please indicate if the family member suffered from any diseases such as cancer, high blood pressure, heart attack, stroke, diabetes, skin disorders or other.

  • Medical History

  • Vaccinations

  • Symtoms

  • Please check off any of the following symptoms that you currently having or have had in the past.

  • Personal Habits and Lifestyle

  • How many cups/bottles/glasses do you drink on average per day?

  • Eating Habits

  • After you click Submit you will be taken to a Thank You page and asked to download a Diet Diary to bring with you on your first visit. Please fill out the Diet Diary completly for one week.

    If you aren't redirected to the Thank You page the form was not submitted.

    If you make any mistakes an error message will appear at the bottom of this page in red.

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