Online Intake 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:

Health Intake and History:

Top 3 Primary Complaints: *

List your issues in order from Worst to Least:

Indicate a pain or aggravation scale for each issue

Check any of the following that you would like to discuss: *

Drag & Drop Files, Choose Files to Upload

Lifestyle:

1-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 one

Consultations Packages:

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