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Pre-Consultation Information Forms

Below are two forms to complete prior to your Initial Consultation.  When finished each, be sure to check for completeness and submit.  This will save significant time in the office for your consultation.  Note that Alinea Natural Health, PMA is a Private Member Organization and no information is shared with any outside business entity or government agency.  All records are only used within the organization and kept private. Thanks so much!

Profile and History 

Please fill out the following form
prior to your initial consultation.

Typical Daily Food Intake:

I specifically authorize the natural health practitioners at Alinea Natural Health, PMA to perform a Nutrition Response Testing (NRT) health analysis and to develop a natural, complimentary health improvement program for me which may include dietary guidelines, nutritional supplements, etc. in order to assist me in improving my health, and not for treatment, or “cure” of any illness or disease.


I understand that Nutrition Response Testing is a safe, non-invasive, natural method of analyzing the body’s physical and nutritional needs, and that deficiencies or imbalance in these areas could cause or contribute to various health problems. I understand that Nutrition Response Testing is not a method for “diagnosing” or “treating” of any disease including conditions of cancer, AIDS, Infections or other medical conditions, and that these are not being tested for or treated.
No promise or guarantee has been made regarding the results of Nutrition Response Testing or any natural health, nutritional or dietary programs recommended, but rather I understand that Nutrition Response Testing is a means by which the body’s natural reflexes can be used as an aid to determining possible nutritional imbalances, so that safe natural programs can be developed for the purpose of bringing about a more optimum state of health.

 

Alinea Natural Health, PMA does not diagnose, cure or treat any illness or disease. Health Coaching provided by Michele Fuller and Alinea Natural Health Staff through Alinea Natural Health, PMA is not intended to, cannot, and should not be expected to substitute for a personal consultation with your own physician.

This permission, consent and understanding of terms and conditions applies to my initial, as all future visits to Alinea Natural Health, PMA.

Thanks for submitting!

Screenshot 2024-02-20 121845.png
INSTRUCTIONS: Select the number that applies to you. If a symptom does not apply, don’t select anything for that symptom.
Screenshot 2024-02-20 121526_edited.jpg
Acid foods upset
Get chilled often

Thanks for submitting!
We’ll get back to you shortly.

Screenshot 2024-02-20 121845.png
Screenshot 2024-02-20 121526_edited.jpg
INSTRUCTIONS: Select the number that applies to you. If a symptom does not apply, don’t select anything for that symptom.
Acid foods upset
Get chilled often

Thanks for Submitting!

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