Welcome to Vita Whole Body Care

Please take a moment to provide us with some information about yourself and your health conditions so that we may do our best to treat you.

VITA Whole Body Care considers this information privileged physicians/patients communication and will hold it in confidence.

Occupation
Emergency Contact Information
Chief Complaint/Major Health Concern:
Family Medical History
Birth History (prolonged, labor, forceps, etc.)
Current emotional health:
Hobbies/Recreational habits:
Please check all significant illnesses that apply:
Please check any symptoms you currently have or have experienced in the past 3 months.
Head, Ear, Eyes, Nose, & Throat Symtoms
Respiratory Symptoms
Gastrointestinal Symptoms
Muscoskeletal Symptoms (Check if you are or have experienced any pain, numbness, or weakness in the following):
Genitourinary Symptoms:
Neurological Symptoms:
Dermal/Skin Symptoms:
Diet and Lifestyle Symptoms:
Emotional Symptoms:
Male Symptoms (Only):
Female Symptoms (Only):
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