Client Intake Form

Please complete the below form in its entirety. More comprehensive helps determine your optimal health path.
Name*
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Chief Complaint*
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Sex*
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DOB*
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Current Medications*
Over the Counter Medications*
Do you see a Physician for any current health issues?*
If so please list
Supplements*
List all surgeries and dates
Any known allergies?*
Any other aspects of your health history we should be aware of?*
Please list diseases or conditions in your family history:
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What time do you normally go to bed?*
What time do you wake up in the morning?*
Do you wake up rested?*
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List your normal day's intake of the following:
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How often do you have a bowel movement?*
Describe your energy level*
What is your favorite food?*
Check All Symptoms That Apply
AcneEdemaPerspirationADD/ADHDEmphysemaPMSAdrenal GlandsEpilepsyPneumoniaAllergiesEyesightPolypsAlzheimer'sFatiguePregnancyAnemiaFeverProstateAngerFluPsoriasisAnxietyGallstonesRashAppetiteGangreneReproductiveArteriosclerosisGasRespiratoryArthritisGoutRestless LegAsthmaGumsRheumatismBack PainThinning HairRing WormBad BreathHeadacheSeizuresBed WettingHeart IssuesShinglesBell's palsyHeartburnSinusBitesHemorrhoidsSkin IssuesBladderHerpesSnoringBlood Pressure - HighHerniaSore ThroatBlood Pressure - LowHivesStomachBoilsHormonesStressBonesHyperactiveStrokeBreathingHypertensionThyroidBronchitisHyperthyroidismTennis ElbowBruisesHypoglycemiaTonsilitisBurnsImpotenceTumorCancerInconstinenceUlcersCandidaIndigestionUrinary InfectionsCanker SoresInsomniaVaricose VeinsCarpal Tunnel SyndromeJoint PainVertigoCataractsKidney IssuesWeight - OverChest CongestionKidney StonesWeight - UnderChest PainLeukemiaYeast InfectionsCholesterolLiverCirculationLung IssuesCold - CommonLupusCold - TemperatureLymph GlandsColicMenopauseColonMentrual CrampsConstipationMigrainesCoughMononucleosisFibroid TumorsCravingsMucusGreat TumorsDandruffNailsFaintingDepressionNauseaFibromyalgiaDiabetesNervousnessNumbness in hands/feetDiarrheaNose BleedsBleedingDigestionParasitesOvariesDizzy SpellsParkinson's diseasePancreasEar InfectionsTMJPacemakerEar RingingDry EyesShunt, ImplantBleeding GumsBurping/GasGum Disease
Other Symptoms
Please note: The material presented by "Pure Nutrition + Wellness" is a result of personal study and experience. The practitioners at Pure Nutrition + Wellness are not licensed physicians. "Pure Nutrition + Wellness" does not engage in the diagnosis of disease or the prescription of any health program as a cure for disease. The material and resources offered by "Pure Nutrition + Wellness" is intended for educational purposes only. Be sure to consult with your personal physician regarding the treatment of any medical condition.
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Important Notice for All Pure Nutrition + Wellness Clients

Due the strong demand for office visits and new client appointments, Pure Nutrition + Wellness requests at least 24 hours advance notice for all appointment cancellations. Please review our policy for cancellations and missed appointments:
Cancellations/Missed Appointments
We do understand that in today's busy world occasionally situations come up that are beyond our control. In those instances, kindly call 844-787-3935, Ext. 1 and give us 24 hours advance notice if you are unable to keep your scheduled appointment time.

Pure Nutrition + Wellness will charge $79 for cancellations received less than 24 hours prior to appointment time, except for cases of medical emergency, and for all missed appointments.

Credit Card on File Clients who would like for us to place supplement orders through the front desk, or who wish to consult with Donna Stephens by phone will need to keep a valid credit card on file with Pure Nutrition + Wellness.
Client Initials
Because we appreciate our clients, we make every effort to create an environment that ensures their privacy!

It is the office policy of Pure Nutrition + Wellness LLC, Essential Calming Solutions LLC, and Gainesville Bodyworks that our practitioners are available by appointment only. In the best interest of each individual, no outside interruptions are permitted when we are in sessions with clients.

Violation of this policy may result in being refused any further consultation or access to other services provided by the practitioners located in the office at 560 Broadview Avenue, Lower Level Warrenton, VA 20186

Thank you for your compliance.
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