Health Intake Form

Thank you for taking the time to tell me more about yourself prior to our discovery & consultation session. All information will be kept confidential.

Name

First Name

Last Name

Email Address

Phone

What is your main health concern?

What have you done in the past to work on this health condition (include both Eastern & Western modalities)?

What has proven effective?

What is your current diet like? Please be specific: list breakfast, lunch, dinner, and snacks, as well as the times you eat.

Are you taking any supplements? Please list what you take and what it’s for.

What would you like your health to be 3 months from now? How about 6 months from now?

What obstacles, challenges, and struggles do you come up with regarding diet/lifestyle?

What is motivating you to invest in your health and vitality at this time?

What do you hope to get out of our time together?

What are 5 things you LOVE about your life?