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Home
Articles
Services
Stress Assessment Survey
System Survey
Listen to a live show
The 19th Element Recent Shows
Your Immunity Project Recent Shows
Client Intake Form
Protocols
Shop
Contact Us
Client Intake Form
Home
Client Intake Form
Your Name (required)
Your Email (required)
Cell Phone
Alternate
Last 4 of SSN
Address
City,State,Zip
Shipping Address
Referred by:
Your Occupation:
Your Employer:
Date Birth
Age
Gender
Male
Female
Your Height
Your Weight
Rate your Heath on a scale from 1-10
Write in your own words, your list of complaints or issues which concern you. What's wrong or bothering you? **Do Not Repeat What Others May have told you about yourself**
Select all that apply (Explain if check)
Cancer
Diabetes
Kidney Failure
HIV/AIDS
Handicapped
Infectious Disease
Trauma
Hepetitis
Covid 19
Herpes
Heart Disease
Stroke
Hypertension
Mental Illness Emotional Upsets Digestive Issues
Other
Have you had a Covid nasal swab test? If so, list dates.
List 5 Related Goals or Abilities you desire to achieve.
Select all medications/drugs/substances being taken
Coffee
Tea
Prescriptions
Alcohol
Cocaine
Marijuana
Supplements
Vitamins
Herbs
Other
Please list all prescriptions and supplements your are currently taking.
Are you currently under the care of a physician or other health care professional(s)? (If yes, please provide name)
List any major illness(with approx. dates)
List any Past Accidents or injuries:
Martial Status
Single
Married
Divorced
Widowed
Any family history of serious illness?
Cancer
Diabetes
Heart
Other
Describe health of your spouse
List Children (if any) with their age and sex. Are there any physical conditions or concerns?
Any household pets or other animals you or family members are in close contact with
Submit
