Health Consultation Form

Personal Information

Today's Date:
Name:*
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Age:
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Health Information

Medical Conditions:
Allergies:
Social History	Caffeine UseExercise Tobacco ChewingCigarette Use Alcohol UseIllegal Drug Use
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Reason for Consultation*
Health Notice	The information obtained from this consultation is educational in purpose and reflects the Biblical lifestyle designed by God to promote health and wellness. However, this information is not intended to diagnose or treat disease but can be used as a supplement to explore the outcome of God’s natural remedies. As always, before making any lifestyle changes, Rapid Awakening Health encourages you to consult your primary care physician for your personal health care needs.
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