Need Help? Call: 520-326-8300

Rooted Integrative Wellness Intake

*FILLING OUT THIS FORM DOES NOT MEAN THAT YOU HAVE REQUESTED AN APPOINTMENT. PLEASE CALL (520) 326-8300 TO SCHEDULE*

Personal Info
Contact Info
Emergency Contact
Doctor
MVA history

PLEASE NOTE: The following list of conditions isn't exhaustive. Please use the "Other" fields at the bottom to provide any missing conditions or details.

Conditions/Health History
Area(s) of Complaint - select all that apply
Headaches
Neurological
Cardiovascular
Reproductive
Immune
Musculoskeletal
Gastrointestinal
Blood
Skin
Respiratory
Ear/Nose/Throat etc.
Kidney
Endocrine
Miscellaneous
Pregnancy
Medications
Injuries
Surgeries
Review & Agree