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​CORRECTIVENUTRITION.COM

 PRELIMINARY HEALTH INTAKE FORM

 If you are contemplating becoming a client, it would be necessary for you to fill this form out, print it and either mail me a hard copy or e-mail it. By filling out and sending the below information, you are not committing to anything nor am I; however, it is necessary for me to have certain information about you and your situation so that I can determine whether or not I could be of assistance to you.
               
    

PRELIMINARY HEALTH INTAKE FORM

DATE_______________________
NAME______________________________________
ADDRESS__________________________________________________________________________________City______________________________  State _________ Zip code _____________
PHONE NUMBER(S)__________________________________________________
E-MAIL___________________________________________________________



HEIGHT_______ WEIGHT________ AGE____BLOOD PRESSURE___________
PULSE______ TEMPERATURE_____
WHAT IS/ARE YOUR MAJOR COMPLAINTS?
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FAMILY HISTORY?
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WHAT DO YOU THINK ARE THE CAUSES OF YOUR HEALTH PROBLEMS?
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HOW LONG HAVE YOU HAD THIS/THESE CONDITIONS?
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 WHAT TREATMENTS, INCLUDING DRUGS ARE YOU PRESENTLY
UNDERGOING OR HAVE HAD IN THE PAST?   (Please specify if present or past)

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RESULTS OF THESE TREATMENTS/SUBSTANCES?
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SURGERIES? (And dates)
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  • Home
  • Testimonials
  • Services Offered
  • Curable Pathologies
    • ​ Symptom Complexes
  • resume
  • Contact
    • Intake Form
  • Disclaimer