Neighborly Wellness Intake Form

First name

Last name

Email

Phone

Birthday

Month

Day

Year

I understand that Charles "Chip" Paul is NOT a medical professional and that any tests performed at Neighborly Wellness are NOT medical diagnostics. Further that Neighborly Wellness cannot treat or diagnose disease. Do you consent to this information?

By checking the box and consenting, you are agreeing to hold Charles "Chip" Paul, Neighborly Wellness, TrueMedX LLC, GnuMedX LLC, and GnuAnalytics harmless for any actions or results from any counseling, testing, suggestion, or products offered or discussed during any sessions.

I consent to receive communications related to my program.

I consent to the use of my de-identified data for learning and improvement.

Symptoms

Severity

Hormones

Medications

Diseases

Have you fainted or nearly fainted recently?

Yes

No

Have you been told you have uncontrolled high blood pressure?

Yes

No

Have you had black vomit or black/tarry stools?

Yes

No

Are you experiencing signs of severe dehydration (dizziness, very low urine output)?

Yes

No

Important:

If you are experiencing severe chest pain, difficulty breathing, fainting, or signs of internal bleeding, seek immediate medical care or call emergency services. This form is not for emergencies.

Who We Are

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