New Client Intake Form
Please Fill Out The Details Below
Date Completed by Client
Date of Birth
Is it ok to contact you by email and/or by text message?
Emergency Contact and Phone Number
Number of Children
Please list your ongoing symptoms or diagnosis:
Please tell us your primary health concern:
Please tell us your primary health goals at this time:
Primary Care Provider
Approximate Date of Last Physical Examination:
Approximate Date of Last Blood Test:
Other Clinicians Consulted for the Complaints Listed:
Have you had diagnostic testing in the past five years such as X-ray, MRI, CT?:
Medications Using Presently:
Vitamins or Supplements Being Used Presently:
Vitamin or Supplement Adverse Reaction(s):
Please list any known food or drug allergies:
Do you regularly eat Wheat/Gluten?
Do you regularly eat Dairy?
Did you work in an industrial environment?
Do you have a household member(s) working with and/or around environmental toxins?
Please describe any emotional issues you feel you have:
Please tell us if you have any pain and its location:
Exercise (# of days/week):
Please List Any Known Family History of Disease
Do you have a willingness to make lifestyle changes?
Please tell us your expectations:
Limitations recorded by patient:
How motivated are you on a scale of 1 to 10 to meet your goals?
Please list any other concerns you have:
Notice Of Privacy Practices
I acknowledge that Back to Health Natural Solution’s “Notice of Privacy Practices” has been provided to me.I understand I have a right to review Back to Health Natural Solution’s Notice of Privacy Practices prior to signing this document. Back to Health Natural Solution’s Notice of Privacy Practices has been provided to me.The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Back to Health Natural Solution’s. The Notice of Privacy Practices for is also provided on request at the main administration desk of this practice. This Notice of Privacy Practices also describes my rights and Back to Health Natural Solution’s duties with respect to my protected health information.Back to Health Natural Solution’s reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.
Client Printed Name
After clicking 'Submit' be sure to check your email or spam folder for our Welcome email which will allow you to schedule with us.
Should be Empty: