Health Assessment and Risk Form

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Fill out all of the information below so we can individualize your care plan. If you have any questions regarding the form, please contact us through quick chat located at your lower right hand side of the screen.

PERSONAL INFORMATION

SOCIAL INFORMATION

HEALTH INFORMATION

Chief Complaint:

Lack of Energy

Sluggish Digestive

Poor Sleep

Sadness

Poor Eating Habits

Sedentariness (Lack of Exercise)

Joint & Body Aches

Overeating

Weight Gain

Frequently Sick

Intense Sugar Cravings

Seizures

COPD ( Chronic Lung Disease)

Uncontrolled Blood Pressure| Sugar

Co-Morbidites (All That Apply):

Hypertension

Diabetes

High Cholesterol

Cancer

Hypothyroidism

Depression

Arthritis

Woman's Condtion (PCOS,Fibroids, etc)

Asthma / COPD

Heart Conditions (Arrythmia)

Seizures

Obesity

Main Health Concern

Additional Health History / Current Medications

LIFESTYLE INFORMATION

What percent of your daily intakes are fruit and vegetables ?

What percent of your daily intakes are animal products (meat, cheese, butter, milk, eggs, etc) ?

What is your Activity Level ?

Not Consistently Active

1-2 days of activity a week

3-4 days of activity a week

Active Most Days of the Week (5+days)

Thanks for submitting!

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