Thrive Worldwide Wellness Initial Intake Form

Thrive Worldwide Wellness

Client Initial Intake Form
Dear Friend,

Thank you so much for reaching out to Thrive Worldwide Wellness and for taking the first step towards greater health!

This intake form is required before any appointment requests can be granted. Once you complete and submit this form you will receive an email from one of our team members to help book your free 30-minute wellness consultation with me, Amber Summers, HHP, HNC, Founder of Thrive Worldwide Wellness.

The information you provide in this Intake form helps me to better understand your case and make the most of the short time we will have together. This form is protected under HIIPA standards for client privacy so please feel safe to share any medical conditions or concerns.

I'm looking forward to meeting you and hearing about your wellness challenges and goals. It is my greatest passion to support individuals in healing themselves and living their best life!

If you have any questions or concerns leading up to your scheduled visit, or if this is an urgent or critical case and you need to be seen sooner, please contact us directly through email at thriveworldwidewellness@gmail.com.

Again, thank you for your inquiry and I look forward to meeting with you soon!

Yours in Wellness,

Amber
Basic Information
Name
Email Address
example@example.com
Time Zone
Phone: Home #
Phone: Cell #
Address

Address

Street Address Line 2

CityState

Zip Code
Birthdate

MonthDayYear
Date
Sex Assigned at Birth

MaleFemale
Current Gender

MaleFemaleOther
Referred By
Emergency Contact Information
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone
Occupation
How would you like to be notified of appointments?

TextEmailBoth
Marital Status
Number of Children
Primary Care Physician
Primary Complaint(s): Please list major symptoms and concerns
Secondary Complaint(s):
Are you currently experiencing pain as a result of these symptoms?

YesNo
If yes, please describe the pain:
When did the pain begin?
Medical History: Please list any and all medical conditions, dates of occurrence and treatments. Include surgeries, accidents, and other traumas, etc.
List of Allergies/Sensitivities
Have you taken antibiotics in the past six months?

YesNo

Medications: Please list all medications and their intended use

	Medications	Intended Use	Dose
1
2
3
4
5
6
7

Supplements: Please list all supplements and their intended use

	Supplements	Intended Use	Dose
1
2
3
4
5
6
7

Family History: Please list any and all diseases/conditions that run in your family
Symptoms: Please check all that apply to you personally in the last 6 months

Abdominal PainAddictionAlcohol UseAnxiousnessArthritisBlood ClotsBreathing DifficultyBroken Bones/FracturesCancerChest PainChills/FeverCirculatory ProblemsCold Hands/FeetColitisConstipationCoughCrampingCystic TumorsDental fillings/ Metal fillingsDepressionDiarrheaDiabetesDifficulty ConcentratingDizzinessEpilepsy/SeizuresExcessive PMSFaintingFatigueFrequent ColdsGenital TroubleHeadachesHealth ComplicationsHeartburnHeart DiseaseHeart PalpitationsHigh Blood PressureHyperthyroidismHypothyroidismHysterectomyInsulin PumpIrritabilityJoint ReplacementKidney DiseaseKidney StonesLimited Use of Limbs/ParalysisLiver DiseaseLow Blood SugarLower Back PainLung DiseaseMetal ImplantsMigraine HeadachesMuscle StiffnessNauseaNeck PainNeurological ProblemsNon Rx Drug UseNumbnessOsteoporosis/OsteopeniaPacemaker/DefibrillatorPoor AppetitePoor CoordinationPregnancyProblems EatingRectal PainRelationship ChangesRoot CanalSciatic PainSinus TroubleSkin EruptionsSore ThroatSpinal ProblemsStrokeSwollen AnklesTension in Neck and ShouldersThoughts of SuicideToo Much SleepToo Little SleepUlcersWeakness in BodyWeight GainWeight LossOther
Have you ever consulted with any of the following:

AcupuncturistChiropractorDoctor of NaturopathyIridologistLife/Wellness CoachMassage TherapistMedical DoctorNutritionistPhysical TherapistPsychiatristReflexologistRolfer
Any Other Specialists
How did you hear about us? Check all that apply:

Friend/FamilyEventNatural AwakeningsPractitioner of ThriveFacebookInternet SearchYelpNewspaperTelevisionRadioHouse of NutritionOther
What topics are you most interested in learning more about?

Acupressure/Acupuncture TCMAromatherapy/Essential OilsDetoxificationHolistic MedicineHolistic Certification ClassesHomeopathyHypnosisIridologyLife CoachingLyme SupportMagnetic Therapy (PEMF)MassageMeditationMetabolic RebootNutritionOrganic Skincare/FacialsPast Life RegressionRaw Foods/JuicingReflexologyReikiSound TherapySupplementsTai Chi/Qi GongWeight LossYoga
I verify that, to my knowledge, all of the information listed above is accurate.
Signature

Clear
Date

MonthDayYear
Date
Property of Thrive Worldwide Wellness
Thrive Worldwide Wellness
Client Privacy Acknowledgement

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my health information. I understand that this information can and will be used to:
- Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved directly and indirectly in that treatment.
- Obtain payment from third-party payers (if applicable).
- Conduct normal healthcare operations such as quality assessments and practitioner certifications (if applicable).
I have been informed by Thrive Wellness Center, LLC of the Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you may restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand Thrive Wellness Center, LLC is not required to agree to my requested restrictions, but if Thrive Wellness Center, LLC does agree then Thrive Wellness Center, LLC is bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that Thrive Wellness Center, LLC has taken action relying on this content.
Client / Guardian
Signature

Clear
Date

MonthDayYear
Date
Guidelines for Treatment

HOLISTIC HEALTHCARE & NUTRITION CONSULTATIONS

Services Offered: Holistic Healthcare and Nutritional Consultations utilize Asian and European traditional evaluation techniques. Techniques can include but are not limited to analysis of the tongue, fingernails, pulse, Japanese Hara, and iridology (analysis of the iris Treatments suggested may include change in diet, juicing, cleansing, and the use of vitamins, supplements, and/or homeopathic remedies aimed at supporting and strengthening the body's natural abilities to heal itself.

Note: Certified Holistic Healthcare Practitioners are not licensed medical doctors. The techniques, analyses, and evaluations utilized during a Holistic Healthcare Examination are not considered medical diagnoses. For a medical diagnosis for any concerns, please see your physician.

Office Hours: Hours are available by appointment

Emergencies: In cases of urgent need, please call our main phone number. If it is after hours, please leave a message and a staff member will return your call the next business day. If you are experiencing a medical emergency, seek immediate medical treatment.

Missed Appointments: If an appointment needs to be cancelled or rescheduled, please make an arrangement 24 hours in advance free of charge. If you give 12 hours notice, you will be charged half the price of your service. If you don't call to notify us and/or don't show to your appointment, you will be charged the full amount of your service.

Prior to Your Appointment: For an initial consultation appointment, please submit the intake forms at least 24 hours prior to the appointment. Please make sure you have a stable internet connection and the Zoom app downloaded on your computer or mobile device.

I have read and understand the above guidelines, and agree to the following:

I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile, and understand that there shall be no liability on the practitioner's part should I forget to do so.
Signature

Clear
Date

MonthDayYear
Date
THRIVE WORLDWIDE WELLNESS CANCELLATION POLICY

Please be considerate of our practitioners time by honoring our cancellation policy:

Thrive Worldwide Wellness asks that you give 24-hour notice prior to cancelling your appointment. If client does NOT provide at least 24-hour notice, a $25 cancellation fee will be charged to the card on file. If no card is on file, a bill will be sent to the client's address. We understand emergencies occur and are happy to grant a one-time pass for extenuating circumstances.

I have reviewed and understand the cancellation policy.
Client Signature

Clear
Date

MonthDayYear
Date
NO CALL / NO SHOW POLICY
100% of service price will be charged to the card on file for each No Call/No Show appointment. If no card is on file, a bill will be sent to the client's address. We understand emergencies occur and are happy to grant a one- time pass for extenuating circumstances.

I have reviewed and understand the No Call/No Show policy.
Client Signature

Clear
Date

MonthDayYear
Date
Thank you for completing our intake form. A member of our team will contact you by email within one business day to help schedule your free consultation.
Should be Empty:

Thrive Worldwide Wellness

Thrive Worldwide Wellness

NO CALL / NO SHOW POLICY