Health History 

 Health History Questionnaire

The Health History questionnaire is used to gather client health information to assess your history and current health status and behavior. This information is private and confidential. Please fill out as much information as possible for an accurate assessment.

Stay Connected!

  • Facebook
  • Instagram
  • LinkedIn

DISCLAIMER: Neither First Wave Wellness nor Jacqueline Day is acting in the capacity of a doctor, licensed dietician-nutritionist, mental health provider, psychologist or other licensed or registered professional. No content, advice, information or program contained herein are intended to be a substitute for professional medical advice, diagnosis or treatment that can be provided by your own physician, nurse practitioner, physician assistant, therapist, counselor, mental health practitioner, licensed dietitian or nutritionist, member of the clergy, or any other licensed or registered health care professional. Do not disregard professional medical advice or delay seeking professional advice because of information you have read on this website, or its content, or received from us. If you are under the care of a health care professional or currently use prescription medications, you should discuss any dietary changes or use of dietary supplements with your doctor, and should not discontinue any prescription medications without first consulting your doctor.  If you have or suspect that you have a medical or mental health issue, contact your own health care provider promptly. We are not providing health care, medical or nutrition therapy services or attempting to diagnose, treat, prevent or cure in any manner whatsoever any physical ailment, or any mental or emotional issue, disease or condition. We are not giving medical, psychological, or religious advice whatsoever.