• Intake Form

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  • Please check ALL of the following symptoms, which you now have or have had in the past year. Be as thorough as possible! Your health history is strictly confidential.


  • Please describe the what and when of any situation below:

  • Have you ever:

  • Habits

  • I certify to the best of my knowledge that the above information is accurate and that if anything changes in regards to my health I will notify someone from the Internal Harmony Team immediately.

  • Should be Empty:
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