Online Intake FormPlease enable JavaScript in your browser to complete this form.DISCLAIMER I am not a physician and the relationship between you and I is not of a prescriber and patient, but as an educator and resource provider sharing healthy information. The material content provided and taught by About Your Health, LLC is educational and informational in nature and is provided only as general information and does not constitute medical or psychological practice, advice, opinion, diagnosis, treatment, or guarantee. The content does not create any doctor-patient, therapist-patient or any other professional relationship and is not a substitute for medical diagnosis, advice, or treatment, or other professional health care. For the avoidance of doubt, About Your Health, LLC cannot and does not provide specific treatment advice to anyone. If you have questions about this, please contact About Your Health, LLC. You are responsible for your own health care decision-making and should obtain necessary consultations with appropriate healthcare professionals. It is fully your responsibility and choice as to whether or not you take advantage of the healthy information presented to you which can be found as public knowledge. Information about Homeopathy may be discussed during your consult. Homeopathy does not treat an illness. It stimulates the body’s natural ability to correct conditions that are out balance. It considers the wholeness of a person. Diagnosis from a holistic physician can be pivotal in addressing any condition and is encouraged. Any information shared between you and About Your Health, LLC will remain private and protected. Information will only be shared with your written consent to appropriate medical providers in order to better serve you. Patient Signature:Print: *Sign: *Date *Health Intake and History:Name: *Date: *Age: *DOB: *Email *Phone *Check your preferred method of contact: *EmailTextPhone CallAddress *Address Line 1City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeTop 3 Primary Complaints: *1st *2nd3rd List any Definitive Diagnosis you have been Given: List your issues in order from Worst to Least: Indicate a pain or aggravation scale for each issue Issue 1: *Scale 1: *Date 1: *Issue 2:Scale 2:Date 2:Issue 3:Scale 2:Date 3:Issue 4:Scale 4:Date 4:Check any of the following that you would like to discuss: *Checkboxes *Alcohol/Drug AddictionAllergiesAnemiaEating DisordersArthritisAsthmaBack ProblemsBladder InfectionsDepressionPneumoniaMigrainesBronchitisEndometriosisFibroidsIrregular PeriodsNo PeriodsHeavy Menstrual BleedingPainful MensesPre-MenopausalMenopausalHot FlashesGoutPrevious MiscarriagesFood AllergiesGallbladder IssuesInsomniaPanic AttacksOverweightThyroid DiagnosisWartsHigh Blood SugarHigh Blood PressureKidney StonesIBSDry SkinPsoriasisAnaphylactic ReactionStrokeEczemaLow Blood PressureADHDLow Blood SugarColitisAcneUTIsChronic FatigueHepatitisUlcersEpilepsySinusitisEar InfectionsHivesShinglesDiabetesDementiaHeat StrokeSleep ApneaBrain FogAdrenal FatigueKidney DiseaseFatigueSeizuresCravingsHeart BurnNauseaBells PalsyStomach PainVomitingAcid RefluxWeaknessOtherList all Supplements and Medications you are currently taking, reason for taking and how long you have been on them: If the list is lengthy and you already have them typed up, you may send an attachment in PDF. Only PDF file is allowed.Upload Medication Attachment Drag & Drop Files, Choose Files to Upload Lifestyle:Do you have any allergies? *YesNoPlease list them here:Please list them here: *How many hours a day do a sleep? *How many glasses of water do you drink daily? *The type of water you drink daily *Number of alcoholic drinks Daily? *Number of Cigarettes Daily? *Type of Caffeine daily and amount?Number of times you eat Fast Food Weekly?Do you eat fruits and vegetables Daily? *YesNoHow many servings of each? *Do you grind or clench your teeth? *YesNoHow Many Bowel Movements do you have daily? *1-23-41-2 a weekOtherPlease mention other *Are your bowel movements…? *Hard like popcorn ballsSoft and easy to passLong like a snakeLiquidDiarrheaContain undigested FoodMucus in stoolCheck your average level of daily stress: *12345678910Do you think you need to lose weight? *YesNoDo you exercise? *YesNoHow Often: *Daily2-3 x Weekly4-7 x weeklyWhen was the last time you were prescribed an antibiotic?Did you have to take more than one round of antibiotics?What is your idea of living a “Healthy Life?” Scale for you How committed are you to making new food choices, lifestyle changes or adding nutrients where gaps exist in your diet on a scale of 1-10? *123456789101-not committed at all, 5-somewhat committed, but money and time are obstacles, 10 highly committed “ I’m ready to achieve my best health!” Additional supplements and medications can be listed here. Be sure to include how long you have been taking each oneName 1Reason Why Taking 1How long been taking 1Name 2Reason Why Taking 2How long been taking 2Name 3Reason Why Taking 3How long been taking 3Name 4Reason Why Taking 4How long been taking 4Name 5Reason Why Taking 5How long been taking 5Name 6Reason Why Taking 6How long been taking 6Name 7Reason Why Taking 7How long been taking 7Name 8Reason Why Taking 8How long been taking 8Name 9Reason Why Taking 9How long been taking 9Consultations Packages:*First 15 min are complimentary to see if we are a good match for a working relationship.3 – (1) Hour Consults = $420.00Ask About The Pricing For Broadcasting ServicesPay as you go$185.00 per hour$95.00 per 30 min.Submit