Intake Form – Fundamentals Challenge | Sari's Natural Medicine

FUNDAMENTALS CHALLENGE INTAKE FORM

Please complete the following form. Your answers are important for us to make sure you are safe during your Fundamentals Challenge
Your Name(required)
Date of birth/ age(required)
Email address(valid email required)
Phone number(required)
Postal address(required)
Post code(required)
List your past medical history(required)
List your current medical history(required)
List any medications you are taking, prescribed or over the counter(required)
List any supplements or herbal medicines you are taking(required)
Have you done Nutritional Balancing before?
YesNo
List any detoxification procedures you have done before.
List any heavy metals/ heavy toxin exposure you have had if any.
Briefly list your top three health concerns
Briefly list your top three health goals
Thank you for your time. We look forward to working with you during your Fundamentals Challenge and in the future.

HTMA testing, Nutritional Balancing and Naturopathy is not a substitute for medical care. It is not a means of diagnosis, treatment, prescription or cure for any disease or condition, mental or physical. It is a means of reducing stress and rebalancing, strengthening and restoring body energy and chemistry. When this is done, many health conditions will improve over time.

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