Judy DeLorenzo, Holistic Health Practitioner

Holistic Health Practitioner, Medical Medium Inspired, Supplement Discounts

I suggest completing this form from a computer or laptop, not from your smart phone.  This form doesn't autosave, so if using a laptop make sure your battery doesn't run out or you'll lose your work.

CONFIDENTIAL INTAKE FORM
Name *
Name
Home Phone
Home Phone
Cell Phone
Cell Phone
Address
Address
Please check off all that applies
Which system(s) are CURRENTLY NOT in good health? Good health is measured by an absence of pain, symptoms, sensations and disability.
Which of the following have you recently consulted?
Check all that apply past or present
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Women please check off what applies to you
Please check off all that apply regarding your diet
Indicate all of the types of cookware that you use (regularly or occasionally). If you are not sure if you are using aluminum or stainless steel, please check the underside of pots/pans for information
Please indicate if you usually consume the following
Please indicate which of the following you consume
Do you consume any of the following or a regular/semi regular basis?
What is your main water source?
Indicate which beverages you regularly consume
Please indicate the places you regularly obtain your groceries
Indicate if you smoke
Please check off which vaccines you have received
Please check off all that apply
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Would you describe your life as physically
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Please indicate which devices are located within your bedroom, or on the wall behind your bed's headboard
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Disclaimer: Judy is not an MD, PA, OD, ND, licensed dietitian or licensed nutritionist, and does not diagnose or treat disease. All information is offered to assist one's innate ability to balance body, mind, emotions & spirit. Clients are encouraged to seek advice from medical doctors in addition to considering complementary and alternative practices. Judy is certified through the American Association of Drugless Practitioners as a Holistic Health Practitioner with advanced training in Transformational Energy Healing and she is an ordained minister through the Universal Light. *