Client Information Form

We would appreciate all of our clients to fill out the information below and submit it, if you haven’t already done so. This way we will know more about the types of health issues you are dealing with, and can provide better services to help you in your healing journey.

If at any time, you want to change your information, just send us an email from the Contact Us page or call. We will be happy to make the adjustments for you.

Name *

First

Last

Email *

Phone Number *

Height (inches): *

Weight (lbs.) *

Age: *

Birthdate: *

Gender: *

• Male
• Female

Main areas of concern:

Please check any of the items below that apply to you.

• Acid Reflux
• Acne
• A.D.D./A.D.H.D.
• Allergies (air borne)
• Allergies (food)
• Alzheimers
• Anemia
• Antibiotic Resistant Disease
• Arthritis
• Asthma
• Autism
• Autoimmune Disease
• Bacterial Infections
• Bloating
• Bronchitis
• Cancer
• Candida
• Cerebral Palsy
• Cold hands or feet
• Cold sores
• Colitis
• Constipation
• Crohn's Disease
• Cystic Fibrosis
• Cystitis
• Depression
• Dermatitis
• Diabetes type 1
• Diabetes type 2
• Diverticulitis
• Dizziness
• Ear Aches
• Eczema
• Endometriosis
• Eye problems
• Fatty Liver Disease
• Fibroids
• Fibromyalgia
• Fungal Infections
• Gall Stones
• Gastritis
• Gout
• Hair Loss
• Hashimotos
• Headaches
• Hemorrhoids
• High Blood Pressure
• High Cholesterol
• Hodgkin's Disease
• Hot Flashes
• Hypothyroid
• Hyperthyroid
• Insomnia
• Irritable Bowel Syndrome
• Joint Pain
• Kidney Stones
• Leaky Gut Syndrome
• Leukemia
• Long Covid
• Lupus
• Lyme Disease
• Migraines
• MTHFR Gene Mutation
• Multiple Sclerosis
• Muscle Pain
• Neuropathy
• Numbness and Tingling
• OCD
• Osteoporosis
• Over Weight
• Pacemaker
• Panic Attacks
• Parkinson's Disease
• Phlebitis
• Prostate Problems
• Psoriasis
• PTSD
• Rheumatoid Arthritis
• Sarcoidosis
• Swelling/Inflammation
• Tinnitus
• Tremors
• Ulcers
• Urinary Infections

Other Concerns:

Where did you hear about us? *

Submit