By Balanced Life Wellness Center
Date of Birth
Please check one or more that apply:
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?
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?
Please list any additional comments regarding your health and well-being:
Any allergies to nut oils?
By submitting an intake form, you agree to the consent below:
You agree to the terms
8080 La Mesa Blvd, #208 La Mesa, CA 91942