Health Intake Form


Please complete the following Health Intake Form to apply. This will allow us to assess if we think you'd be a good fit for our wellness practice. We look forward to speaking with you soon!

Name *
Address *
Phone *
Birth Date *
Birth Date
Gender* *
Today's Date *
Today's Date
(Include children, parents, relatives, and/or friends. Please include ages.) Example: Wendy, age 7, sister
Example: indoors/outdoors
Did you feel safe growing up? *
Have you been involved in abusive relationships in your life? *
Was alcoholism or substance abuse present in your childhood home, or is it present now in your relationships? *
Do you feel safe, respected and valued in your current relationship? *
Have you had any violent or otherwise traumatic life experiences, or have you witnessed any violence or abuse? *
Do you feel comfortable discussing these issues? *
(as a child and adult)
(e.g., Cortisone, Prednisone, etc.)
As a child did you eat a lot of sugar and/or candy?
(List typical meals and snacks)
(Tea, coffee, soda, other caffeine, dairy, cheese, bread, sugar, candy, chocolate, dessert)
Example: fat, protein, carbs, etc.
Example: fat, protein, carbs, etc.
Example: 0-1, 1-2, 3 or more
Level 1 - $150 per month for 4 months Level 2 - $190 per month for 4 months (Includes Genetic Report & Gene Optimization Recommendations)
Congratulations, you are on the path to taking your first step towards health and wellness!
Agreement *