Health Consultation Registration Form ← BackThank you for your response. ✨ Name(required) Email(required) Date of Birth (YYYY-MM-DD)(required) Gender(required) Phone(required) Mailing Address(required) Preferred method of communication (email, phone text) How did you hear about us? (Search Engine, Social Media, or Friend (please list name)). Relationship Status Occupation WELLNESS INFORMATION Please list your main health concerns:(required) Please list your top wellness goals:(required) At what point did you feel your best? Why? Any serious illnesses/hospitalizations/injuries? History of dental surgery, fillings, amalgams, root canals, etc. How well do you sleep? How many hours? Do you wake up at night? Any pain, stiffness, or swelling? How is your digestion? Allergies or Sensitivities? Please explain. Do you take any medications or supplements? Please list and note which ones you’d like tested. (required) Any other healers, helpers, or therapies with which you are involved? What is your relationship with physical exercise? What is your relationship with food? What foods do you eat most often for breakfast, lunch, and dinner? Will family/friends by supportive of your desire to make food and lifestyle changes? How often do you eat home cooked food? Do you experience cravings? If so, what? What do you believe is the most important things you can do to improve your health? MENTAL AND EMOTIONAL HEALTH What thoughts and emotions do you experience most often? Anything else you’d like to share? SendSubmitting form Δ Share this: Share on X (Opens in new window) X Share on Facebook (Opens in new window) Facebook Like this:Like Loading...
