General New Client Health Forms

Welcome!

It was a pleasure speaking with you and on behalf of our office I would like to congratulate you on taking the next step toward improved health and wellness!  We believe you are in the right place and have seen many clients obtain fantastic results!

Please fill out the following information that our office requires you to complete and hand back to us at least 1 week prior to your first visit. We would greatly appreciate it if you would complete and return all forms as soon as possible, as our team requires time to review and prepare for your first visit.

It is critical to bring your spouse or significant other to this appointment. We will be going over a lot of information which may affect the household. Mutual support in any needed changes will be vital to your success.

Additionally, please watch this Required VIDEO, along with your spouse or significant other, prior to your first appointment.

New Client Forms 

1. Please submit the Health Survey Below

If you have had blood work done in the last three months, please provide a copy with the other PDF files below. 

2. Please submit: The Symptoms, 3 Day Diet Recall, Scar/Trauma, and Nutrition Consent Forms

Click link below to download PDF

Please submit them back to our office by:
             - Attaching them to the Health Survey
            - Faxing
them to 262-253-039
            - Scanning and emailing them to: clinic@totalhealthinc.com
            - Mailing them to:  Total Health Nutrition Center Attn: Clinic
                                         N82W15485 Appleton Ave.
                                         Menomonee Falls, WI 53051     

            - Or if you’re local, please drop them off and say hello!

NOTE: If you are having any trouble filling out these forms, please contact out office at: 262-251-2929

 

Health Survey

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Address
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Work Address

Emergency Contact

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Emergency Contact Address
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Patient History

Answer the following questions to the best of your ability. If you don't know the answer, simply leave it blank. 

Mercury

Lead

General Toxicity 

Mold

Lyme Disease 

Health History

Microbiome Health