Global Health Clinic
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Global Health Clinics – Patient Intake Form

Please complete all pages and click Submit button.

Personal Details

Practitioner to Fill : Blood Oxygen Levels

Initial Questions

Please fill in this questionnaire so we can establish what your health and well being priorities are. As a Holistic well being practice, we see health and well being as a mind-body-spirit issue and the information given here will help your practitioner formulate a specific treatment plan for you to achieve your health and well being goals.

Health Professionals & Medications - Health History

Womens Health

Mens Health

General Information

Feelings and Emotions

Rate any of these feelings you have experienced in the last few months:? 1 (not at all) to 5 ( extreme)

Exercise, Stress and Pain Information

Please mark best description for level of stress:

Your Current Diet Sheet

Please indicate amounts of the following per day/week as frequency determines:

Practitioner Notes: