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Intake Form
Intake Form
By Balanced Life Wellness Center
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Intake Form
Name
Sex
Female
Male
Date of Birth
Email
Phone
Occupation
Please check one or more that apply:
DVT
Fungal
HBP
Heart Condition
HIV/AIDS
Skin Conditions
Other
Present Symptoms: What is your major complaint or condition you want to improve?
What have you done to get relief?
Are you under medical/therapeutic treatment?
Yes
No
If Yes, for what condition?
Please list your care providers name and phone number(s):
List any medications (including Aspirin) and nutritional supplements you are taking:
Please list (date and description) any accidents or operations in the last year:
Females: Are you pregnant or any chance you might be pregnant?
Yes
No
Please list any additional comments regarding your health and well-being:
Any allergies to nut oils?
Yes
No
By submitting an intake form, you agree to the consent below:
You agree to the terms
Contact
Address
8080 La Mesa Blvd, #208 La Mesa, CA 91942
Call
619-772-2202
Text
619-772-2202
Email
tmbywendy@gmail.com
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