Intake form

Name *

Email address *

What is your age group?

What is your gender?

What symptoms are you currently experiencing?

Please select at least one option.

Fever

Cough

Headache

Fatigue

Muscle Pain

Shortness of Breath

None

Have you been diagnosed with any chronic illnesses?

Please select at least one option.

Diabetes

Hypertension

Asthma

Heart Disease

None

How would you rate your mental health in the past week?

What type of support are you seeking?

Please select at least one option.

Emotional Support

Crisis Support

General Advice

None

Do you have any allergies?

Please select at least one option.

No Allergies

Food Allergies

Drug Allergies

Environmental Allergies

Which medications are you currently taking?

Additional questions or comments

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