Intake Form: Vital Thread Wellness

Intake Form

Please complete this form to the best of your ability. Your answers will help us understand your health concerns and provide you with the best possible care.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Birthday and Age
Which system would you say you have the most issues with?
Do you have digestion symptoms? Mark all that apply.
Do you suffer from allergies or sinus issues?
Do you have Skin Issues?

Other
Dental Health (check all that apply)
Blood Sugar and Cardiovascular (check all that apply)
Vaccines (check all that apply)
Occupation
Blood Type
Food Sensitivities (check all that apply)

Other
Hormones (check all that apply)
Surgeries

Other
Medications (check all that apply)

Other
For Women: please let me know how your cycle is.
Anything else you would like to add about your health or what you would like to see from the scan?
DISCLAIMER

The purpose of this intake form is to gather general wellness information. It is not intended to diagnose, treat, cure, or prevent any medical condition. The services provided are not a substitute for medical care from a licensed physician or other healthcare professional. By completing this form, you acknowledge that you are responsible for your own healthcare decisions and agree to consult your medical provider for any medical concerns
Signature
CONSENT

I understand that The Vital Thread Wellness works in collaboration with The Health Profiler, Pamela Wingert. By signing below, I consent to have my scan results shared for the purpose of professional collaboration and to help achieve the most accurate and effective results.
Signature
Arbor Vitae & Camden Messier Clients Only

I hereby authorize Camden Messier and The Vital Thread Wellness to mutually share and exchange my health, wellness, and intake information. This collaboration is solely for the purpose of coordinating my care and optimizing my wellness plan. I understand that this consent is voluntary, covers all intake forms and assessment data, and can be revoked by me in writing at any time.
Signature
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