Tree of Life Forms
Followup Health Form
Step
1
of
2
- Health Information
50%
Patient's Name
(Required)
First
Last
Email
Phone
Date of Birth
(Required)
MM slash DD slash YYYY
Considering your overall health, list your biggest health concerns or symptoms and when they started:
Current Height
Current Weight
What weight are you most comfortable at?
How many ounces of water do you drink daily?
How many bowel movements do you have a day?
Are your bowel movements...
Loose
Well formed
Incomplete
Thin
Dry and Hard
Painful
Diarrhea
Need Laxatives
On a scale from 1 to 5, 5 being the highest level of energy, how much daily energy do you have?
1
2
3
4
5
How many hours of sleep do you get at night?
At night, Is it difficult to fall asleep? Or back asleep?
Are you currently pregnant?
Yes
No
Are you currently a nursing mother?
Yes
No
Select your most common feelings or emotions
Nervous
Happy
Obsessive
Stuck
Confused
Angry
Content
Irritated
Other
Other Emotion
Please list all current medications and supplements as well as why you're taking them:
Please list any physical, mental, or emotional changes you have experienced since your previous scan:
Special considerations for remedies
i.e. Vegan Friendly, Alcohol Free, Liquid Only, etc
Today's Date
(Required)
MM slash DD slash YYYY
Consent
(Required)
I agree to the terms and conditions
By submitting this form, whether it is signed or not, I fully understand that our proprietary testing service deals strictly in helping improve general health through better nutritional approaches, improved lifestyle, improved health habits and positive mental attitudes. I fully understand that employees of our proprietary testing service are not licensed physicians and cannot diagnose diseases, prescribe drugs or recommend treatments for specific disease conditions. I understand that all evaluations/analysis performed by are designed to evaluate my inherent constitution and temperament for the sole purpose of helping me to improve my general health through nutrition, habits, and attitudes. I further understand that all evaluations/analysis cannot determine specific disease conditions, and do not replace the diagnostic services offered by licensed physicians. I certify that our proprietary testing service has not suggested that I cease any medical care I may be undertaking. I understand that decisions I make regarding health care are my responsibility and certify that I will not hold our proprietary testing service responsible for the consequences of my decisions. These services are not a substitute for prompt medical attention needed. Natural attempts will be made to relieve discomforts, but if a medical professional is needed, seek medical attention or verify recommendations with a primary physician. I certify that I am here on this and on any subsequent visits or contact, whether by mail, telephone, or in person, solely on my own behalf and not as an agent or representative of any federal, state, county, or local government or private agency on a mission of investigation. I have read and understand the foregoing and agree to the terms and conditions set therein. Your privacy is a top priority. We are committed to your Confidentiality of personal information, and securing it with administrative, technical, and physical safeguards. None of your information will ever be sold.
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