Health History form

Client health history request for mobile services

MM slash DD slash YYYY
Name (This form is confidential)(Required)
Requesting service fror(Required)
Are you currently taking and medication?(Required)
Do you have or have you ever had any of the following conditions? Select all the apply(Required)
Are you currently under the care of a physician for any reason?(Required)
Do you smoke cigarettes?(Required)
Do you have any allergies?(Required)
Do you know of any physical or digestive conditions that could be aggravated by a change in nutrition?(Required)
Are you taking any medication which could cause a reaction while changing nutrition program?(Required)
Does your doctor know that you are beginning a new nutrition program?(Required)
If your doctor knows that you are going to begin a new wellness program, does he/she object?
Do you have the Wellfitness App(Required)
RELEASE(Required)
This field is for validation purposes and should be left unchanged.