IHP Health Intake Form

Todays Date
Birth Date
Current occupation (plus list any previous occupations, if different/relevant)
List past medical and surgical history
List previous hospitalisations
What medications are you taking now?
List all vitamins, minerals, and other nutritional supplements that you are taking now
How much of the following do you consume per week on average?
List your main hobbies and leisure activities
Congratulations, you have taking your first step on the path to health and wellness!

Please read and sign the following disclaimer
I have read and understand everything on this page. I acknowledge that Craig Danehy is a natural health practitioner, and that he does not diagnose, treat or cure any illness or disease. Further, the undersigned releases Craig Danehy from any and all liability for any failure to identify any medical condition or disease. It is understood and agreed that this is not the purpose of his natural health services.

All information provided by the client will be held in strict confidence, and will not be shared 
with anyone without the client’s express permission