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Intake Form

The Nutri-Systems Profile form can help identify body systems that are out of balance based on symptomatology. This is not used to diagnose nor does it give definitive answers. Please fill out the form to the best of your ability and email back to before your initial consultation.

If any of the following symptoms or activities have occurred within the past three months (unless otherwise specified), please indicate by checking: 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring, or N/A if the symptom/statement does not apply.

Client Statement:

I understand and acknowledge that the services provided are at all times restricted to consultation on the subject of health matters intended for general well-being and are not meant for the purposes of medical diagnosis, treatment or prescribing of medicine for any disease, or any licensed or controlled act which may constitute the practice of medicine. This statement is being signed voluntarily.

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Thank you for your cooperation. All information contained on this form will be kept strictly confidential.