Cura Health + Wellness
Intake Wellness Questionnaire
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Month
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Name
First Name
Last Name
Birth Date
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Month
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Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Best number to reach you on
Format: (000) 000-0000.
E-mail
example@example.com
How did you hear about our programs?
What would you like to accomplish most with your health right now (lose weight, sleep better, less stress, come off medications, more energy, etc)?
Please complete the following:
Current Weight: (if you want to share)
Height:
In a perfect world, if you could not fail, how many pounds would you want to lose?
What has been the most difficult thing about losing weight in the past?
Have you ever been diagnosed with any type of cancer?
Yes
No
Are you currently being treated for type II diabetes?
Yes
No
Do you currently have or have you ever been diagnosed with pancreatitis?
Yes
No
Have you ever been diagnosed with a bowel obstruction?
Yes
No
Thank you for completing thi form, we will be in contact with you shortly!
Signature
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Continue
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