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Detox Health Intake Form

Please complete this form before starting your detox program.

Fields marked Required are required.

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Personal Information
General Health Overview

Please rate each score on a scale from 1 to 10. For vitality, 1 = very low energy and 10 = excellent vitality. For happiness, 1 = very unhappy and 10 = very happy.

Weight
Height
Diagnostic Medical History
Do you have any diagnosed medical conditions?
Have you had any major surgeries or hospitalizations?
Are you currently taking prescribed medication?
Do you take any supplements, herbs, or natural remedies?
Main Health Concerns
Mental & Emotional Well-Being
Are you currently experiencing any mental or emotional challenges?
Pregnancy / Breastfeeding
Are you currently pregnant or breastfeeding?
Lifestyle
Do you smoke?
Do you consume alcohol?
Do you use non recreational drugs?
Digestive Health
How is your digestion?
Detoxification & Elimination
Do you currently experience any of the following? Check all that apply.
Allergies & Sensitivities
Do you have any known allergies or food sensitivities?
Intentions for the Detox
Closing

Thank you for taking the time to complete this form. Your answers help me support you in the best possible way during your detox journey.

This detox program is intended to support general well-being and is not a substitute for medical diagnosis, treatment, or professional medical advice. Participants remain responsible for their own health and should consult their healthcare provider if they have concerns about their medical condition.

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