On line health intake form

Personl Information

General Health Qustions

Please answer the following in number of 8 ounce servings per day.

Please answer the following lifestyle questions.

Current health complaints today

Personal Health History

Family History

Review of Systems

Goals for Health and Wellness

Please rate your level of stress in the following areas. (1-low, 10-very high):

On a scale of 1-10 (1 poor and 10 excellent) please rate the following Daily habits:

At Waldman Center for Wellness our goal is to help your overall health. Check the areas that are of interest to you and your long term health:

Health Insurance Information

Signatures

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Patient's signature_________________________________________________________Date____

Spouce's or Gaurdian's signature________________________________________________Date____________

Enter the verification code in the box below.