apply to 4yhealth - health intake questionnaire

Please find below a few questions that will get us started on the path to discussing how we can work together to develop a solution to your health problems . I appreciate you taking the time to complete this first step. Please answer all questions as accurately and honestly as possible. No detail is unimportant :)

The form must be completed a minimum of 24 hours before your scheduled appointment.

Which service are you applying for? *
Name *
Name
Today's Date *
Today's Date
Please register for Skype if you do not have an account. If not possible please specify below.
Date of Birth *
Date of Birth
0 being the lowest, 10 the highest. Think of you work/life balance, your relationships, current health concerns...
0 the lowest (can barely move), 10 the highest (boundless energy, always wired)
How much sleep do you get per night on average? *
I have read and understand everything on this page. I acknowledge Ryan Barby does not diagnose, cure, or treat any illness or disease. Further, by checking the "I Agree" button below I release Ryan Barby 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 their natural health services. *
Waiver

Congratulations, you are on the path to taking your first step towards health and wellness!

* All information provided is for health education purposes only and is not intended to diagnose, treat, cure, or prevent any disease.