The Center For Natural Healing Initial Intake Form Name * First Name Last Name Email * Phone Number * Date of Birth * Occupation * Marital Status * How do you consider your current sate of health? Describe your past health history. Do you take any prescription medications? Which ones and what for? Do you take any supplements? Which ones? Do you use anything recreationally? Smoke, drink alcohol or vape? Please describe your daily eating habits. How often do you have a bowel movement? Are they solid or loose? Please describe your sleeping patterns. Please describe your weekly exercise routine. Do you receive any kind of therapy? What are your health goals? Thank you!
