Health Questionnaire & Consent Form

The Health Questionnaire and Consent Form

Please answer all of the questions as accurately as you can and submit the form a minimum of 72 hours (3 days) before your appointment. We recommend completing this form 1-2 weeks before the appointment time so your questions are most current/relevant.

Private and Confidential

Full Name

First NameLast Name

E-mail Address

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Country

Telephone Number

Date of Birth

Date

Gender

FemaleMaleNon-binary/non-conforming.Prefer not to respond

Have you been diagnosed with any diseases or conditions?

1. Condition (duration)

2. Condition (duration)

3. Condition (duration)

4. Condition (duration)

Do you have any other health conditions Please describe:

Severity 1-10 (10 being severe)

1. Condition (severity)

2. Condition (severity)

3. Condition (severity)

4. Condition (severity)

Do you tend to be sensitive to supplements, drugs, chemicals and/or food?

YesNo

What medication (drugs) are you currently taking prescribed by a medical doctor (include contraceptive medication)? (state daily dosage)

1. Medication (dosage)

2. Medication (dosage)

3. Medication (dosage)

4. Medication (dosage)

Please note below any additional prescribed medications you are taking from a licensed physician:

Please list any additional physical and/or psycho-emotional related questions you have here. We will address these during the consultation.

Disclaimer

I hereby confirm that this information is correct to the best of my knowledge and that I am not withholding any important information. I understand that neither nutritional, bioenergetic, or psycho-emotional advice is intended to replace the advice of medical doctors. Nutritional nor bioenergetic medicine does not diagnose or treat any disease state, nor is it a substitute for the medical treatment of a doctor but it can complement it. If you have a health concern always contact your licensed medical practitioner first.

The information shared in Intuitive Health consultation should not be construed as medical advice, professional mental health advice, or any medical or mental health diagnosis, nor is the information a substitute for professional medical or mental health expertise or treatment. If you have a medical or mental health concern, you should consult with your physical or mental health care provider or seek other professional medical or mental health treatment. Never disregard professional medical or mental health advice or delay in seeking it because of something that you read in this educational report or in any linked materials. If you think you may have a medical or mental health emergency, call your doctor, mental health professional or emergency services immediately.

Cancellation procedures: If you decide to cancel the session (and not reschedule), please do so at least 5 days before the scheduled session for a refund, less the non-refundable credit card or Paypal fees (approximately 5%). Failure to compy will result in being charged the full amount of the session that would have taken place.

The email confirmation you receive right after booking the session provides a link to cancel the appointment.

Date

Signed