Healthologix Client Intake Form
Please complete this confidential form before your first consultation. Your answers help us personalize your wellness journey.
Personal Information
Health & Wellness Goals
Personal Health & Family History
A. Health Information
B. Medications & Supplements
C. Medical History
D. Family History
Physical Health
A. Metabolic Health
B. Digestive Health
C. Reproductive Health (optional if not applicable)
D. Hormonal Health
E. Immune Health
F. Brain Health
Nutrition Information
Mental & Emotional Health
Lifestyle Information
Additional Comments
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