MEMBERSHIP | ALINEA

Profile and History

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

First name

Last name

Address

Email

Height

Phone Number

Date of Birth

Age

Weight

Sex (M/F)

Occupation

Employer

Referred By:

Overall health: Excellent / Good / Fair / Poor

Chief complaint (reason you are here):

Previous treatments for this complaint:

Other complaints or problems you'd like to list for awareness:

Current Prescription and/or Over the Counter medications being taken:

Are you currently under the care of a physician or other health care professionals? (If yes, please give name and date of last visit):

Nutritional supplements you are currently taking:

Do you smoke / other tobacco?

Do you drink alcohol? Approx how much:

Do you drink coffee? Approx how much:

List any major illnesses with approximate dates:

List any surgery or operations with approximate dates:

Past accidents or injuries:

Marital Status: Single / Married / Divorced / Widowed

Name of Spouse if Married:

Describe Health of Spouse if Married:

Number of Children:

Describe Health of Spouse if Married:

Describe Any Health Concerns of Children: Please list Name, Sex (M/F), Age, and Health Condition:

Family history of serious illnesses: Cancer / Diabetes / Heart/ Other:

Any household pets or other animals you or family members are in close contact with?

What can we do to make you happier?

Your Energy Level: High / Medium / Low

Your Stress Level: High / Medium / Low

What do you consider as Stressors in your life right now?

Any difficulty going to Sleep?

How many hours sleep average per night?

Typical Daily Food Intake:

List Breakfast, Lunch, Dinner and Snacks:

How much Water do you drink daily?

List Other Drinks you consume (Tea, Soda Wine Beer Energy Drinks Meal Replacements, etc.)

Do you experience digestive discomfort? If so, when? how often?

Do you exercise? If so, what do you do how often?

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.

have read and agree to the Terms and Conditions listed above

I provide consent for NRT consultation and other services at Aliea Natural Health, PMA.

I understand this informaton is for use within Alinea Natura Health, PMA only.

I declare that the info I’ve provided is accurate & complete

Initials

Thanks for submitting!

Pre-Consultation Information Forms

Profile and History

Typical Daily Food Intake:

INSTRUCTIONS: Select the number that applies to you. If a symptom does not apply, don’t select anything for that symptom.

INSTRUCTIONS: Select the number that applies to you. If a symptom does not apply, don’t select anything for that symptom.