Name *

First Name

Last Name

Phone

(###)

###

####

Select current symptoms (check all that apply)

Autoimmune Condition(s)

Anxiety/Depression

Headaches/Migraines

Allergies/Sinus issues

Fatigue

Body Aches/Pains

Hair Loss

Weight concerns

Constipation/Diarrhea

Mood Ups & Downs

Menstrual Problems

Sleep Issues

Are you currently vegetarian or vegan?

Yes

No

Are you a current smoker? *

Yes

No

How willing are you to make diet and/or lifestyle changes to improve your health? *

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Rate your overall health *

Poor

Fair

Moderate

Good

Excellant

Are you familiar with muscle testing or Nutrition Response Testing? *

Yes

No

Due to a high volume of new patients and limited appointment slots, we require a 48 business hour notification of cancellation or reschedule. If proper notice is not given within 48 hours or the appointment is missed, a $75 fee will be billed. Thank you for valuing the time we set aside for quality patient care. *

Confirm your understanding

I have read and agree to the above terms