INTAKE FORM

                                   Health and Wellness Intake

Name:

Allergies:

Date (s) of service:

Mailing Address:

Contact Phone number:

Email address:

Date of Birth:

Emergency Contact Name and Phone #:

I have been informed and consent to participation in this Holistic Nursing coordinated Care Plan for use today and for future sessions.

If I experience pain or discomfort during the session I will immediately inform the nurse so that treatment can be adjusted accordingly.

I understand that this session will not include diagnosis or prescription of medications nor is it intended to cure physical or mental illness but may include nursing care plan recommendations. 

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I affirm that I have provided accurate health history information to assure goals set are safe for my individual care planning.

In accordance with HIPPA regulations my health information will not be shared without my written consent.

Signature:

Date:

Please share:

Health and Wellness Perception

Your  experience  of your health today: 

Do you perceive your health as:

Declining     Maintaining      Improving

Please identify 3 areas in which you experience Health (physical, emotional or spiritual health)

1.

2.

3.

Identify 3 areas to which you wish improvement in your health (physical, emotional or spiritual areas)

1.

2.

3.

Current Health and Wellness Providers

Please list if active or you feel pertinent to this initial evaluation.

Providers: (PCP, Nurse Practitioner, Specialists, Chiropractor, Acupuncturist , Mental Health providers,

 coaches ,etc.)

Health and Surgical History 

Medications/ Supplements:

Thank you for sharing.       I look forward to our partnership in caring for YOU.