Wholistic HMO Intake

Collective Health Initiative

List any childhood illnesses

List any childhood traumas

List any illnesses over the last year

List any surgeries including dates and descriptions

List any therapy sessions including dates and descriptions

List any prescribed over-the counter or street drugs currently taken or for any duration including length, dosage, and description

List any regular physical activity (exercise, yoga, chi gong, dancing, etc) including duration and frequency

Describe your typical eating habits. Are you or have you tried plant based eating before?

Describe daily water intake in ounces

List any major illnesses in family history

List any illnesses recently diagnosed, suggested, or from the past

Do you or have you ever had any mental health issues? Please describe including any current therapies, herbs, or medications

Describe your energy levels (Highs & Lows, Low often, Average)

Do you have any known allergies?

Please List all Surgeries you have had with dates and details for those that were major or have occurred in the last 5 years.

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You are hereby advised to consult with a physician or other professional health-care provider prior to making any decisions, or undertaking any actions or not undertaking any actions related to any health care problem or issue you might have at any time, now or in the future.

Give Thanks for your submission and we will contact you soon!!!

I•AM•IT

Indigenous

Aboriginal

Man In Trust

Collective Health Initiative

Wholistic HMO Intake