Holistic Health Intake Form
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Name: *
Date: *
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DOB: *
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Gender: *
Weight: *
Height: *
Email: *
Address: *

On a scale of 1-5 (1=Poor, 5=Excellent)

How would you perceive your current health? Please share your reasons for this rating.

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What are your current health concerns?

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Please list any prescription medication and/or vitamins that you are currently taking.
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Have you ever tried a holistic approach to healing yourself? If so, please explain.  *
What has motivated you to start your healing journey? *
On a scale of 1-5, how committed are you to the process of healing yourself?
*
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