Patient Intake Form

PATIENT INTAKE FORM

  1. This should take you approximately 10-15 minutes to complete. Please answer thoroughly and honestly and give the questions due consideration.
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  4. (valid email required)
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  14. 1. How did you hear about Sari's Natural Medicine?

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  19. 5. How motivated and committed are you to improving your health? Please select a number from 1 (not committed) and 10 (very committed).

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  29. 14. Please rate the following on a scale of 1 (poor) and 5 (excellent).
  30. General health and wellbeing
  33. Overall quality of your diet
  36. Sense of calm and relaxation
  39. Quality and quantity of sleep
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  43. Exercise and general activity levels
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  47. 15. To improve your health and wellbeing you may be asked to make some changes to your diet and /or lifestyle. If requested to do so, how willing would you be to do the following? Please rate on a scale of 1 (not willing at all), to 5 (extremely willing).
  48. Significantly modify your diet:
  50. Engage in regular exercise/ activity:
  52. Practice relaxation techniques on a regular basis:
  54. Modify your sleep habits:
  56. Have consultations to assess your progress:
  58. I understand that Nutritional Balancing is a means to reduce stress and balance body chemistry. It is not intended as diagnosis, treatment or prescription for any condition or disease.
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  61. Thank you. I look forward to working together with you to help you reach your health potential.
 

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