Interim Health Update Form

For Existing Clients Between Visits

Name

First Name

Last Name

Phone

(###)

###

####

Date

Health Changes

Have you had any new surgeries or hospitalizations, including dental work, urgent care?

Have you been out of the country, on vacation? If so where? Where you ill during the trip or after?

Have you added/changed any new medications or supplements, including antibiotics or any over the counter medication?

What are any upcoming or medical/health screening appointments do you have scheduled?

Have you seen a doctor, health practitioner or specialist since our last appointment? If so, what actions were taken?

Have you been ill? what actions did you take? (over the counter meds, antibiotics?

Have you started or stopped any supplements on your protocol? Have you added any new ones or changed brands??

Have you had any vaccinations since our last visit? (Including allergy shots or covid shots)

Have you been diagnosed with any new health conditions?

Have you experienced any new or good/worsening symptoms?

If yes to any, Please Describe

Lifestyle Updates

Any significant changes in diet, exercise or stress levels?

Additional Notes or Questions?

Have you moved or relocated?