Intake Form

First Visit Client Information

* Indicates required field

Name *

First

Last

Telephone Number *

Cell Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Occupation *

Email *

Birthday

Month *

Day *

Year *

Age *

Gender *

Birth Place *

Marital Status *

No. of children *

I Hereby Attest To The Following Statement:

I acknowledge that the Nutritional Profile, Evaluation, and Suggested Nutritional program and any supplemental materials such as Vitamins, Minerals, Enzymes and Herbs are not for the “diagnosis”, treatment, cure, alleviation, prevention, or care of any “disease” of any kind, in any way. I agree that I am totally responsible for obtaining qualified medical assistance for any such services, or for the care of any “disease” or “pathological” condition. Nevertheless, I reserve myself the right to use the knowledge I gain from the consultation in any legal manner I may choose in the care of my own body. I further declare that the sole reason for requesting the services from this office is for obtaining a “Suggested Nutritional Program” for the building of my health and well-being.

I recognize that analysis is a revolutionary and unorthodox approach to health, and that it is based in Jesus Christ. Being of sound mind, I have chosen this method of building my health of my own free will and in exercise of my Constitutional Right of the attainment of life, liberty, and the pursuit of happiness. Consultations are limited to education in matters pertaining to the improvement in the overall health and physical fitness for maintenance of the best possible state of physical, mental and emotional health. These subjects may or may not include examination or urine and saliva. Such procedures are not for the diagnosis or treatment of any health condition or disease. Any procedures including fasting are at my own choice.

I am fully aware of the fact that the services being provided to me are spiritually oriented, and that those who counsel me have been educated in an alternative counseling discipline. I realize my God given rights and Constitutional rights, which allow me to seek the best care and education for my own personal needs. I am aware that I am entitled to receive information from my counselors about any method of procedures to be used, fees to be charged and the approximate length of procedure, if it can be determined by personal experience, testimonies and suggestions.

I am free to obtain a second opinion from another practitioner at any time I feel it necessary. I understand that all I say is to be kept confidential, and that information concerning myself can be released to another alternative health practitioner only with my signed consent.

I hereby grant, to my counselors to act in my behalf in matters concerning my health with alternative ways. I authorize them to perform any and all health services for me that I have a right to perform for myself and agree to hold them blameless for any and all such acts.

I am not representative of a branch of a municipal, state or U.S. government, the American Medical Association or the Federal Drug Administration.

I have read and fully understand the above listed information and I do hereby request that I be allowed to participate in a health consultation program for the following reasons:

Reason(s) *

Personal Health History

GENERAL INFORMATION

1. Currently taking any medications? *

Yes No

If so, what medication? *

2. Are you involved in any alternative/preventative care? *

Yes No

How long? *

3. What is your main concern? *

4. What are your goals for your health/life? *

5. List any current symptoms or problems *

6. What are (3) three factors in your life that seem most important to your daily health? *

REVIEW OF SYSTEMS/SYMPTOMS

7. Mark a check by a symptom you have or have had in recent years. Put another check if the problem occurs often; and put another check if it is a regular difficulty.

Weight loss or gain *