Initial Questionnaire – Integrative Weight Loss Program

 

Please answer each question in as much detail as possible.

I understand that Suzie Weber is a Naturopath and not a medical doctor. I give permission for my health history to be kept on file for the purpose of naturopathic treatment; I understand that all information within my file will be kept confidential at all times. All information given within this questionnaire is to the best of my ability and is a true and accurate representation of my health.