Troy Farwell Holistic Health Intake Form

Name

First Name Last Name

ALL FIELDS MUST BE FILLED OUT

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Email

example@example.com

How old are you? Birthdate.

Height and Weight

Do you smoke?

Do you partake in any recreational drugs?

Are you Pregnant?

Do you have any allergies? If so what?

Tell me about yourself, hobbies and passions!

#1 Health Concern: Date occurred and action taken.

#2 Health Concern: Date occurred and action taken.

#3 Health Concern: Date occurred and action taken.

#4 Health Concern: Date occurred and action taken.

Accidents/ Surgeries (list and date)

Health Professionals currently being seen: List name and purpose.

What is your goal with consultation? be specific.

What level of stress do you experience daily? List your top three stressors.

What time to you go to bed and how good is your sleep? How do you feel in the morning?

Any family history that would be helpful to know?

List all prescription drugs currently taken, Also list any other prescription drugs taken in the past 5 years.

What supplements are you you currently taking? Be very specific with brands and dosage.

Do you drink Alcohol? If so what and how often.

How much water do you drink? What kind of water? Hot or cold?

What do you eat for Breakfast? What time?

What do you eat for Lunch? What time?

What do you eat for Dinner? What time?

Do you eat snacks between meals? If so what?

How many bowel movements a day do you have?

Are you Happy? explain your answer.

What is your purpose in life?

Any other specific health goals that should be addressed?

Health Disclaimer

All health and health-related information discussed within a Troy Farwell Holistic Health consultation is intended to be general in nature and should not be used as a substitute for medical treatment by a health care professional. Your health-care provider should be consulted regarding matters concerning the medical condition, treatment, and needs of you and your family.

Policies

Troy Farwell Holistic Health is an educational wellness provider, providing education to individuals looking for specific knowledge with health concerns. It is 100% the individual learner’s responsibility to take advantage of the education provided. There are no guarantees with any Troy Farwell Holistic Health program or consultation. It is 100% the individual learner’s responsibility to take responsibility for their individual health and make sure all educational programs, services, and consultation sessions are in adherence with their individual health care providers. Troy Farwell Holistic Health does not diagnose or acts as a medical facility.

Financial Obligations

All Payments are to be made in Full: Payment plans are available for the Rejuvenation Packages. Any missed appointments will be counted as a consultation and will be billed as one. A 24-hour notice is required for any cancellation. Email cancellation is NOT a form of cancellation accepted by Troy Farwell Holistic Health. Any missed consult will be billed at $50.00 and must be paid in full before the next consult will be booked. There are no refunds on any programs after 7 days. No refunds on individual consults.

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Inner Alchemy with Troy Farwell