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Health History form
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Health History form
Health History form
Client health history request for mobile services
Date
(Required)
MM slash DD slash YYYY
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.
Comments
This field is for validation purposes and should be left unchanged.
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