Register/Login Create AccountExisting AccountHealth Assessment Form & RegistrationUsername:First Name:Last Name:Email:Password:ShowAddress (Line 1)Address (Line 2)Birth DateAge18192021222324252627282930313233343536373839404243444546474849505152535455565758596061626364656667686970+Phone NumberEmergency Contacttype in the phone number of your emergency contact (If any)CityStateZip CodeCountryOccupationNumber of years in field of work0123456789101112131415161718192020+the number of years you have worked at your current occupationRetired: Number of years in retirement123456789101112131415161718192020+If are not currently working and in retirement, please select the number of years you have been retired.Health Conditions hepatitis HIV high blood pressure seizures pacemaker blood-thinning meds pregnancy surgically implanted joint/bone replacement or stabilizersPlease indicate if any of the following pertain to you: (indicating "yes" does not make you ineligible for treatment, however, it may redirect some of your treatment modalities)Are you currently under the care of any other health care provider (physician, chiropractor, therapist, massage therapist, etc.)? Yes Noif yes, please provide the condition being treated and the length of time you have been receiving this treatment:ConditionLength of TreatmentPlease list all past medical conditions for which you were hospitalized and/or received surgery (include the dates)Past Medical ConditionsCurrent health ConcernsPlease List Your health concerns in order of priorityWhat do you believe is cuasing your most important health concerns?How does it impact your quality of life?Have you seen a physician or other health practitioner about this? Yes NoIf yes, then when?What was the Diagnosis? (if any)Describe any treatment you received and results:What aggravates this condition?Habits and LifestyleDo you smoke? Yes NoIf yes, then what?How much per day?Since when?Do you drink alcohol? Yes NoIf yes, then what?How much per day?How often?Do you exercise regularly? Yes NoIf yes, please describe what you doPlease select your emotional stress on a scale of 1-101) no stress2)3)4)5 )moderate6)7)8)9)10) extremelyWhat do you do when you want to release stress and/or relax?How many hours do usually sleep per night?When do you go to bed?Do you wake feeling refreshed?What is your height?What is your current weight?How often do you have a bowel movementNutritionDo you drink coffee? Yes NoIf yes, how much per day?Do you drink caffeinated tea? Yes NoIf yes, how much per day?Do you drink soda pop? regular diet noneplease check oneIf yes, how much per day?Do you have regular eating habits? Yes NoPlease describe a typical day's diet for you:breakfastlunchdinnersnacks (what hour?)Medications/Supplementsplease list any medications and supplements you are currently taking, along with doses and the reason you take them.Medications and supplementsplease list all current medications and supplements you are taking Everything I have written and answered in this form is true to the best of my knowledge. I will update this office when there are significant changes. I agree to the conditions and terms of service.RELEASE AND WAIVER OF LIABILITY AND INDEMNITYTHIS FORM MUST BE SIGNED BY ALL PARTICIPANTS. IF PARTICIPANT ISUNDER 18 YEARS OF AGE, FORM MUST BE SIGNED BY MINOR AND HIS/HERPARENT/GUARDIAN.IN CONSIDERATION of the undersigned Participant being permitted to voluntarily utilize theUpland Hills Health, Inc. ("Upland Hills") Wellness Center (the "Center") facilities, equipment,programs and services, participant and, if applicable, Participant's undersigned Parent/LegalGuardian (individually and collectively referred to as "Participant") hereby:1. ACKNOWLEDGES, agrees and represents that Participant understands that the Centeractivities involve certain risks. Participant also acknowledges that there are potentialrisks of which may presently be unknown. Participant understands that Wellness GuideCenter does not insure participants in Center treatments, that any coverage shall bethrough personal insurance at Participant's expense and that Wellness Guide Centerhas no responsibility or liability for injury resulting from Participant's utilization of theCenters nutritional suggestions.2. FULLY RELEASES, WAIVES DISCHARGES AND COVENANTS NOT TO SUEWellness Guide Center , its Board, agents, employees or designees from any and alllosses, causes of action, claims, damages or liability that Participant, Participant'sspouse, child(ren), guests, legally authorized representative, assigns, successors andrepresentatives may have that relates to, arises out of or is any way connected toParticipant's use of the Center or Participant's participation in Center nutritionalsuggestions.3. AGREES TO DEFEND INDEMNIFY AND HOLD HARMLESS Wellness Guide Center,its Board, agents,Employees or designees from and against any and all claims of any nature including all costs,expenses, and fees arising out of or resulting from Participant's actions during the Center’sprotocols.4. CONSENTS to receive emergency medical treatment which may be deemed advisablein the event of accident or illness while participating in the protocols.By signing below, Participant acknowledges that s/he has had the opportunity to review, discussand ask questions about the terms and conditions contained herein.PARTICIPANT ACKNOWLEDGES THAT S/HE HAS READ THIS RELEASE AND WAIVEROF LIABILITY,UNDERSTANDS ITS TERMS, UNDERSTANDS THAT S/HE WILL BE GIVING UPSUBSTANTIAL RIGHTS AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUTANY INDUCEMENT OR GUARANTEE BEING MADE.Wellness Guide Center Informed Consent to TreatI hereby request and consent to the performance of treatments and other procedure within the scopeof practice of Naturopathic Therapies (or on the patient named below, for whom I am legallyresponsible)I understand that methods of treatment may include, but are not limited to: Organic supplements,herbal medicine, and nutritional counseling. I understand that the herbs may need to be prepared andthe teas consumed according to the instructions provided orally and in writing. The herbs may have anunpleasant smell or taste. I will immediately notify a member of the center of any unanticipated orunpleasant effects associated with the consumption of the herbs or treatment.By voluntarily signing below, I show that I have read, or have had read to me, the above consent totreatment, have been told about the risks and benefits of Holistic treatment and other procedures, andhave had an opportunity to ask questions. I intend this consent to cover the entire course of treatmentfor my present condition and for any future condition(s) for which I seek treatment.UsernamePasswordForgot Password?
