Client Intake Form
Please fill out the following form and submit it before your first appointment.
Do not close, refresh or navigate away from this page while you are completing your form.
A. Basic Information
B. Health Goals
C. Health History
What is your daily (approximate) consumption of:
Do you use any of the following? And for how long each day?
Please select any symptoms you’re currently experiencing, experience often, or have recently experienced:
F. History with other practitioners
Please complete a 3-4 day Daily Food Record and submit it at least 24 hours prior to your first appointment.
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