Please answer all questions honestly and with the intent of providing as thorough a picture as possible of your health history.
This form is confidential. This information cannot and will not be given to anyone outside this office without your written permission!
Successful diet and health assessment are only possible when the practitioner has a understanding of the patient physically, mentally, and emotionally. However, if any of these questions are difficult to answer or talk about, please let the practitioner know.
The nature of your responses to the following questions will go a long way in assisting my understanding of you. Your time, thoughtfulness and honesty are greatly appreciated!