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Blog
Contact

Health History Intake Form

Name

Date

Phone

Email Address

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Date of Birth:

Mother's Date of Birth:

Father's Date of Birth:

What are your current health concerns?

Please list any surgical procedures you have had along with the date or year:

Do you have any root canals?YesNo

If yes, how many?

Please list any medications you currently take (including over the counter) and what condition they were prescribed for:

What Supplements are you currently taking? Please include the brand and dosage.

Do you use recreational drugs?YesNo

If yes, please explain:

Do you smoke?YesNo

Do you consume caffeine regularly?YesNo

Do you drink soda pop?YesNo

Do you drink tap water?YesNo

Reverse OsmosisYesNo

DistilledYesNo

How much water do you consume daily?

Do you eat fresh fruits and vegetables?YesNo

If yes, how many servings?

What is your current stress level?

110

What is the main reason for stress, if any?

Do you exercise?YesNo

If yes, how often and what form of exercise?

Are you currently pregnant?YesNo

Are you currently breastfeeding?YesNo

Family History

Additional Information

Save as Draft

Disclaimer – Sheila VanHemert is not a medical doctor, nor does she claim to be. She does not diagnose or treat disease. Her sole mission and purpose is to educate on proper care of your body/health and to nutritionally support your system so it can repair itself. Our bodies are fearfully and wonderfully made, and given the proper attention can, and will, heal itself.