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Confidential Health Assessment

 

 

Vibrational Medicine Initial Consultation Intake Form

Client information form to be completed prior to first session. Note: if you leave this page without saving or submitting your form, your information may be lost.

Step 1 of 2

50%
  • (day/month/year)
  • Enter your preferred contact email address here.
  • (work, cell, home)
  • What are your expectations for electing to work with Kathy and vibrational remedies?
  • Diet / Nutrition

    Please complete - list / name all that apply. Typical food intake / consumption.
  • Food Intake

    Please describe and list what you typically or most often eat at the following meals and snack times.
  • What do you usually eat for breakfast?
  • When do you usually eat breakfast?
  • What is a typical lunch for you?
  • When do you usually eat lunch?
  • Describe a typical dinner meal.
  • When do you usually have dinner?
  • List food items you typically eat as snacks.
  • When do you usually have a snack during the day? Can be multiple times.
  • Average consumption of the following - please check one

  • Cow's milk, cheese, yogurt, etc.
  • (coffee, tea, cola, chocolate)