Intake Forms

Please COMPLETELY fill out and submit the Client Health Questionnaire form below 24 hours before your Appointment with ANY of the Modalities*

**(Completely filling out the intake forms will help us to best prepare for your scheduled appointment and save you time having to finish completing the form in the office.)

** (Your information is private and will not be shared)

Please Call 480.594.5052 to schedule your appointment

We are here to advise which therapies will provide the most benefit and success for your goals based on our experience

PLEASE FILL IN ALL BOXES. IF SOMETHING DOES NOT APPLY TYPE “NA” or “NO”. TYPE “NA” OR “NO”FOR ALL RELATED QUESTIONS. IE: ” PLEASE IDENTIFY , PLEASE EXPLAIN , PLEASE LIST

Client Health Questionnaire

Personal Information:

Full Name

Date

Email Address

Cell Phone

Home Phone

Work Phone

Address

City

State

Zip

Date of Birth

Age

Occupation

Emergency Contact

Relationship

Phone

Marital Status: Maried Single

Height

Weight

Sex: Male Female

Physicians

Primary Care:

Phone:

Address:

City:

State:

Zip:

State

Health Questions:

1. How did you find My Leading Edge Wellness? Referral - Internet Search , Advertisement, Referral ( if referral please identify )

2. Have you had alternative health therapies before? Yes No

If yes, please identify

3. Which therapies are you currently using?

4. How have these therapies helped you?

Medical History

5. Are you currently under medical supervision? Yes No

If yes, please explain

6. Are you currently taking any medications? Yes No

If yes, please list below

Please explain the conditions that you have marked above:

8. Do you have any implanted electrical devices such as a pacemaker, cochlear implant, intrathecal pump, insulin pump, etc…? Yes No

If yes please list:

9. Do you have any implanted metals such as joint replacements, dental implants, mechanical heart valves, metal stents or metal staples in blood vessels? Yes No

If yes please list:

10. Do you have breast implants or organ transplants? Yes No

11. Do you take immune suppression medications? Yes No

12. Do you have hypotension? Yes No

13. Do you have Graves' Disease? Yes No

14. Do you have Epilepsy? Yes No

15. Are you pregnant? Yes No

16. Have you had any surgeries? Yes No

If yes, please identify the type and date of each surgery:

17. Is there anything else about your health history that you'd like to mention:

Consent and Release

I understand and agree that: (1) any statements made by Leading Edge Wellness and about its services have not been evaluated by the Food and Drug Administration (FDA); (2) Leading Edge Wellness does not diagnose, treat, cure or prevent disease; and (3) Leading Edge Wellness is not a “Covered Entity” under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). In consideration of being permitted by Leading Edge Wellness to participate in their services, I hereby waive any and all claims and damages for personal injury or death that may occur as a result of my participation. I understand and agree that: This Consent and Release is intended to discharge in advance Leading Edge Wellness, it's officers, officials, employees, agents, and volunteers from and against all liability arising out of or connected in any way with my participation in Leading Edge Wellness; I indemnify and hold harmless Leading Edge Wellness, its officers, officials, employees, agents and volunteers from any loss, liability, cost or expense, including litigation of any form, arising out of or connected in any matter with my participation in Leading Edge Wellness; I have no physical condition which would preclude me from safely participating in Leading Edge Wellness; and I understand and agree that this Consent and Release is intended to be as broad and inclusive as permitted under the law of the State in which it is executed and that if any portion of this Consent and Release should be determined to be invalid, it is my intent that the remaining portions shall continue in full force and effect.

Digital Signature

PRINT NAME

DATE

FILL OUT INTAKE FORM COMPLETELY AND HIT SUBMIT

TESTIMONIALS

Leading Edge Wellness™ does not provide medical advice, diagnosis or treatment through this Website. The purpose of this digital publication is to explore current research and discussions of holistic natural therapies and healthy lifestyle factors that are typically not discussed in the realm of modern allopathic medicine.

The content of this Digital Publication, such as text, graphics, images, and other material has not been evaluated by the FDA and is for informational purposes only. The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read, heard or seen on this digital publication. When you schedule an appointment with Leading Edge Wellness™ you will be given natural therapies to support your healing, but they are not a substitute for medical treatment.

480-594-5052