Get Balance Patient Intake Form - Holistic Health Assessment

Completing the Balance Patient Intake Form - Holistic Health Assessment is a crucial step in ensuring you receive the most effective holistic care. This guide provides clear, step-by-step instructions on how to fill out the form online, enabling you to provide essential information about your health and wellness.

Follow the steps to successfully complete your intake form.

1. Click 'Get Form' button to access the form and open it in your preferred digital editor.
2. Enter today's date at the top of the form. This should reflect the date you are filling out the form.
3. Provide your full name in the designated field to ensure accurate identification.
4. Select your gender by marking the appropriate option with an 'X'.
5. Fill out your home address, city, state, and zip code to help establish your local context.
6. Include your email address for future communication regarding your health and wellness.
7. Indicate your date of birth and age. If you are under 18, include the name of the person responsible for your account.
8. Provide your phone numbers, including home, work, and cell, to ensure you can be contacted easily.
9. Fill out information for an emergency contact, including their name, relationship to you, and contact phone number.
10. Select your marital status by checking the appropriate box.
11. Indicate whether you are a caregiver for any dependents, and specify how many children and adults you care for if applicable.
12. Enter your occupation and the number of years you have been engaged in this type of work.
13. For insurance coverage, fill out necessary details such as subscriber name, relationship to patient, insurance company, plan number, group number, and effective date.
14. List your primary care physician and any other health practitioners you see along with the conditions they are treating you for.
15. Specify the reason for your visit and list your current health concerns in order of priority.
16. Document any past hospitalizations, surgeries, procedures, or injuries including dates.
17. Record any medications you are currently taking, along with the dose and reasons for taking them.
18. Likewise, document any supplements you are taking, detailing the reason, starting date, dose, and whether they have been helpful.
19. Provide detailed family health history, including ages and major illnesses for each family member listed.
20. Check off any medical conditions that apply to you from the provided list.
21. Complete the sections for women's health and men's health if applicable, providing any relevant details.
22. Indicate any symptoms you have experienced in the last year across the various categories.
23. Address habits and lifestyles by completing the emotional stress scale, smoking and drinking habits, exercise routine, and nutrition concerns.
24. Conclude by filling out the sleep and relaxation section, providing details about your sleep patterns.
25. Before finalizing, sign the form to verify that all information provided is true to the best of your knowledge.
26. Save your changes, then download, print, or share the form as needed.

Complete your Balance Patient Intake Form online today to take the first step towards your holistic health assessment.