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Patient Enrollment Form

I. Patient Information

Full Name

Date of Birth

Gender Identity

Preferred Pronouns

Marital Status

Occupation

Employer

II. Contact Details

Primary Phone Number

Email Address

Mailing Address

City

State

Zip Code

Preferred Contact Method

Phone Text Email

III. Emergency Contact Full Name Relationship Phone Number

IV. Referral Information How did you hear about us?

Website Social Media Friend/Family Practitioner Event Other

V. Health Information Are you currently under the care of a physician or mental health professional?

Yes No

Are you taking any medications or supplements?

Yes No

Have you had any recent surgeries, diagnoses, or major health concerns?

Yes No

Are you currently pregnant?

Yes No N/A

Do you have a history of (check all that apply):

Chronic Pain Anxiety Depression High Blood Pressure PTSD Autoimmune Disorder Cancer Diabetes Other

VI. Wellness Goals & Intentions What brings you in today? (Feel free to be as detailed as you'd like) What are your primary goals for our sessions? (select all that apply)

Stress Relief Emotional Healing Pain Management Spiritual Connection Chakra Balancing Energy Clearing Chronic Dis-Ease Management Autoimmune Dis-Ease Relief Other

VII. Consent & Acknowledgement

I acknowledge that the services provided are not a substitute for medical care and do not diagnose, treat, or cure disease. I understand that I should consult with my healthcare provider for any medical concerns.
I give permission to be contacted for appointment reminders, wellness updates, or follow-ups.

Signature

Date

“”As a dedicated clinical nutritionist, I deliver expert virtual consultations combining scientific nutrition therapy with personalized guidance to empower you toward optimal health.”

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Contact Info

United States

info@housen.telehealthpractices.com

609-200-0204

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