Pre-consultation Form

Full Name*

First NameLast Name

Date of Birth*

Date

Contact Number*

Area CodePhone Number

Email Address*

example@example.com

Address*

Street Address

CityState / Province

Postal / Zip Code

Check the conditions that apply to you:*

Check the symptoms that you' re currently experiencing:*

Are you currently taking any medication?*

YesNo

Are you pregnant?*

YesNoNot applicable

Do you smoke?*

What is your occupation?*

Do you have any allergies? If Yes, what kind?*

Any family health history that would be helpful to know?*

List all prescription drugs currently taking.*

What supplements are you you currently taking? *

What is your goal with consultation? Be specific.*

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

What kind of drugs? How long have you used/been using them?*

Health Disclaimer

All health and health-related information discussed within Withlove-ai 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

Withlove-ai 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 Withlove-ai 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. WIthlove-ai does not diagnose or acts as a medical facility.

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