Name *

First Name

Last Name

Date

MM

DD

YYYY

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Are you currently taking any medications? *

Yes

No

Are you currently pregnant?

Yes

No

Planning to be

Do you take in high amounts of any of the following?

Caffeine (4+ servings per day)

Nicotine (5+ cigarettes/vape breaks)

Alcohol (7+ drinks per week)

Fast Food (2+ times per week)

Water (64 ounces/half a gallon per day)

Do you now, or have you recently had any respiratory or flu symptoms? *

Yes

No

Have you had a fever in the last 24 hours? *

Yes

No

Have you been in contact with anyone in the last 14 days who has had COVID-19 symptoms? *

Yes

No

Would you prefer your practitioner to wear a mask during your appointment?

I have no preference, without is just fine.

Yes, please!

Please note any symptoms you may be currently experiencing or have experienced in the past:

Halitosis

Gingivitis

Mouth Ulcers/Canker Sores

Belching (excessive)

Heartburn/Gastroesophageal Reflux (painful, acidic, cramping in chest)

Gastritits

H. Pylori Infection

Gastroparesis

Fatty liver disease

Pancreatitis

Diabetes

Flatulence (excessive)

Celiac Disease

Non-Celiac Gluten Sensitivity (NCGS), and Non-Celiac Wheat Sensitivity (NCWS)

Constipation (frequent)

Diarrhea (frequent)

Diverticular Disease/Diverticulitis

Irritable Bowel Syndrom (IBS)

Inflammatory Bowel Disease (IBD) (Crohn's Disease, Ulcerative Colitis, Microscopic Colitis, and Ischemic Colitis)

Hemorrhoids (frequent)

Bloating (excessive)

GERD

Nausea (frequent)

Headaches or Fatigue (frequent)

Kidney Stones

Other (noted below)

Cancellation Policy Acknowledgement *

I acknowledge this business's 24-hour cancellation policy stating that should I cancel within 24 hours of my reserved appointment time, or that if I do not show up, I am still responsible for paying for 100% of the service I had scheduled.

I understand.