Intake Form Hastings Healthy Living Intake Form Thank you for taking the time to fill this out prior to your health consultation. All information will be kept confidential. First Name: Last Name: Address: City: State: -Select One- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas United Kingdom Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip: Email: How often do you check mail: Home Phone: Work Phone: Cell Phone: Health Information What is your main health concern?: What have you done in the past to work on this condition? (western or eastern modalities): What has proven effective?: What is your current diet like?: Are you taking any medications or suppliements?: Where would you like your health to be 4-6 months from now?: What obstacles, challenges and struggles do you come up with regarding diet/lifestyle?: What do you hope to get out of this consultation session?: What is one thing you LOVE about your life?: Additional Comments Anything else you would like to share?: