Facebook
Twitter
Instagram
LinkedIn
Mail
Home
Mobile
Become an Affiliate
Health History form
Newsletter
Registration
Health and Wellness Lifestyle Membership
Menu
Menu
Health History form
You are here:
Home
1
/
Health History form
Health History form
Client health history request for mobile services
Date
(Required)
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Name (This form is confidential)
(Required)
First
Last
Email
(Required)
Phone
(Required)
Property/Location
(Required)
Requesting service fror
(Required)
Weight management
Detoxification
Blood pressure
Diabetes
Cholesterol
Energy
Immunity
Recovery
Anxiety
IV Therapy
Sexual health
Inflammation
Botox
Jeuveau
Dysport
Fillers
testosterone
Mounjaro
Wellness Life coach
none of the above
Are you currently taking and medication?
(Required)
Yes
No
If yes, list name of medication and reason
Do you have or have you ever had any of the following conditions? Select all the apply
(Required)
Heart Attack
Stroke
Chest Pain
Hypertension
Diabetes
Cancer
High Cholesterol
Hernia
Arthritis
Thyroid
Anemia
Other
None
If other, explain here
Are you currently under the care of a physician for any reason?
(Required)
Yes
No
If yes, explain here:
Do you smoke cigarettes?
(Required)
Yes
No
If yes, how much?
Do you have any allergies?
(Required)
Yes
No
If yes, explain:
Do you know of any physical or digestive conditions that could be aggravated by a change in nutrition?
(Required)
Yes
No
If yes, explain:
Are you taking any medication which could cause a reaction while changing nutrition program?
(Required)
Yes
No
If yes, explain:
Does your doctor know that you are beginning a new nutrition program?
(Required)
Yes
No
If your doctor knows that you are going to begin a new wellness program, does he/she object?
Yes
No
Do you have the Wellfitness App
(Required)
Yes
No
Best time to contact
(Required)
Morning
Afternoon
Evening
Comments
RELEASE
(Required)
By checking the box I agree to the following release
I am not aware of any physical or medical condition which I, or my Doctor, feel could be aggravated by changing my current Health, Wellness, and Beauty program. I agree to advise in writing if any of the above information changes or if my Doctor advises me to stop, reduce, or otherwise adjust my Health, Wellness, and Beauty regiment. The information I have given on this form is, to the best of my knowledge, complete and accurate. I understand that this information will be shared with licensed and or certified medical professionals to complete the services or services I have requested.
Phone
This field is for validation purposes and should be left unchanged.
Scroll to top
X
Newsletter Signup
Sign up now and never miss a thing!
X
You're Signed Up!
Now that you are signed up, we will send you exclusive offers periodically.