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The cost of this service is $25. We will email you back a plan after Dr. Nelson reviews your answers. 

When you come in for your new client appointment, just bring the receipt in that you paid for this, and we will take $25 off of your initial appointment.

Name*

Email Address*

Reason for health evaluation*

Phone number (including dashes)*

Address (with postal code)*

Birthdate*

Please describe your sleep patterns*

Bowel habits? - normal, constipated, explosive, diarrhea?*

Please describe your stress level*

Please describe your energy level*

Are you in any type of pain? Please describe.*

How many ounces do you drink of the following - water, coffee/tea, alcohol, soda, other?*

Women - please describe menstrual patterns.*

Men - do you have jock itch or athlete's feet*

How many times in your life have you been on antibiotics?*

Select an option

List all medications and why you are taking them.*

What are your top 3 health concerns?*

Do you want me to put you on our prayer list?*

Select an option

Please check off anything that applies to your health history

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