History & Intake Form

For new clients, this form should be filled out and brought with you at the time of your appointment. Please fill out the information to the best of your knowledge and recollection.


Additionally, please bring all supplement bottles, a list of any prescribed and/or over the counter medications, and a copy of any recent labs.  This will help us use this time more efficiently.


Click here to download this form



General Questions

This questionnaire is specifically designed to enable appropriate and effective homeopathic treatment. 

While some of the questions may seem irrelevant to your immediate health concerns,  they are important to determine your overall health picture. 


Please answer the questions in as much detail as possible and bring the completed form with you to your initial appointment.  If you find any of the questions difficult to answer, please feel free to skip those.


Click here to download this form


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5701 North High Street, Suite #208, Worthington, OH  43085



We offer: In Person, Phone & Virtual Consultations

Office hours open Monday-Saturday.



© Copyright 2020 Empowering Better Health, LLC.  All rights reserved.


Disclaimer: The statements made in here have not been evaluated by the Food and Drug Administration and represent the professional opinion(s) of the author. The purpose of this is not to act as a personal physician to any reader and is not meant to directly or indirectly diagnose disease, dispense medical advice, or prescribe the use of any products or services as treatment for sickness or disease. This information is for educational purposes only. You should always cooperate with a licensed health professional of your choice with the goal of creating optimal health. Please consult your physician prior to implementing any of the strategies mentioned in this web site or starting any diet, exercise, or health program—especially if you are pregnant or nursing. Any application or use of the information, resources, or recommendations contained here is at your own risk.

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