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Pre-Appointment Information Forms

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The forms below are to be completed for new clients having an initial consultation for Natural Health improvement through Alinea Natural Health, PMA (a member of the Alinea Wellness Group LLC).

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Please take your time and fully complete all information and submit each form. 

 

This will greatly faciliate information exchange and preparation for your visit :)

 

If you have any questions, feel free to call or message us at 301-582-3009, or email office@alineanaturalhealth.com and we will get back to you asap for assistance.

You can navigate to specific forms using the buttons below.  You may come back later to complete subsequent forms if you'd like.  Please fully complete and submit each separate form before leaving though, to ensure that the info is saved. If you want to complete them all now, simply click the "Next" buttons at the bottom of each form when finished.

New Client Information Form

Alinea Natural Health,PMA

Contact Information

Gender at Birth
Male
Female
Marital Status
Do you smoke?
Yes
No
Do you drink coffee?
Yes
No
Do you drink alcohol?
Yes
No

History

Family history of serious illnesses:

Current Health Survey

Your Energy Level:
High
Medium
Low
Your Stress Level:
High
Medium
Low
Any difficulty going to Sleep?
Yes
No

Your Typical Daily Food Intake (describe what you eat and approximate times of day:

Do you also drink (check all that apply):

PERMISSION & AUTHORIZATION FORM REGARDING THE USE OF

NUTRITIONAL RESONSE TESTING

     I specifically authorize the natural health practitioners at Alinea Natural Health, PMA to perform a Nutrition Response Testing health analysis and to develop a natural, complimentary health improvement program for me which may include dietary guidelines, nutritional supplements, etc. in order to assist me in improving my health, and not for treatment, or “cure” of any disease.

     I understand that Nutrition Response Testing is a safe, non-invasive, natural method of analyzing the body’s physical and nutritional needs, and that deficiencies or imbalance in these areas could cause or contribute to various health problems.

     I understand that Nutrition Response Testing is not a method for “diagnosing” or “treating” of any disease including conditions of cancer, AIDS, Infections or other medical conditions, and that these are not being tested for or treated.

     No promise or guarantee has been made regarding the results of Nutrition Response Testing or any natural health, nutritional or dietary programs recommended, but rather I understand that Nutrition Response Testing is a means by which the body’s natural reflexes can be used as an aid to determining possible nutritional imbalances, so that safe natural programs can be developed for the purpose of bringing about a more optimum state of health.

Alinea Natural Health, PMA does not diagnose, cure or treat any illness or disease. Health Coaching provided by Michele Fuller, Sarah Pentz and Alinea Natural Health Staff through Alinea Natural Health, PMA is not intended to, cannot, and should not be expected to substitute for a personal consultation with your own physician.

Understanding of Above and Consent

This permission form applies to subsequent visits and consultations.

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