Health History Questionnaire

Basic Information


 

 

Emergency Contact


 

 

Referral Information


 

 

Details for your Visit


 

 

Medical History


 

 

 

 

 

 

 

Agreement & Submit


I understand wellness services are designed to be a health aid and are in no way to take place of doctor’s care when it is indicated. Information exchanged during any session is educational in nature and is intended to help you become more familiar and conscious of your own health status and to be used at your own discretion. “I have completed the medical history to the best of my knowledge and I understand the practitioner does not diagnose conditions or prescribe medications.