Intake survey form

The Natural HEALTH SOLUTIONS Center

10 6th Street, Bristol, TN 37620 – Phone: (423) 968-1536

Hello, We invite you to fill out this form to let us know what your health issues and goals are. We will respond with an email containing information on how we would approach helping you with health issues or goals. Sincerely, David Luther, Director.

First Name:

Last Name:

Address:

Email Address:

Phone Number:

Please check any of the following conditions that apply to you: (choose from the drop-down menu below):

NUTRITION RELATED

Primarily NON-NUTRITION RELATED

Other (write it in):

ALLERGIES

ENERGY LEVEL: Please check one of the following:

Low
Fair
Good
Excellent

If you could change one thing about your health, what would it be?

Would you like to receive our free newsletter via e-mail:
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The Natural Health Solutions Center offers its products and services in an effort to help our clients improve their overall state of health. We do not offer these products or services as cures for any disease. Our recommendations are not meant as a substitute for advice from your doctor. If you have a serious or potentially serious health problem, please see a doctor. You may wish to use our suggestions in addition to the treatment prescribed by your doctor. If so, it is best to do so with his or her knowledge.

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Date:

Signature: Please type your full name