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Well-Being Intake Form (health history)

-This form is confidential and will ONLY be read by Dr. Kevin Reese and or his team of health coaches. 

-If you're including photo's for a posture alignment assessment, please follow these directions...

Please have someone take 4 head to toe photos of you from the front, back, right side and left side. There's an example at the bottom of this form. 

Please stand in front of a one color background. Either a wall or door. 

We need to see your joints, so make sure your shoulders, knees, and ankles are bare.

Tank tops can work well as long as you tuck it in. However, men would benefit from going shirtless and women would benefit from wearing sports bra’s. 

Wear shorts, spandex or boxers that do not cross your knees and can show some of your thigh (femur). If your shorts are long, please fold them up.   

No shoes or socks please. It’s also ideal to not wear the color black for a shirt.

Wear what you’re comfortable with, but the more of the muscular skeletal system Dr. Reese can see the better. 

Make sure you have some decent lighting and don’t pose! We need you to stand as natural as possible. It’s suggested to march in place 3-5 times and let your feet and arms stop at a place of normalcy for you. Then keep your eyes straight ahead, don’t smile. The more natural you stand, the better assessment can be made. 

After you fill out this form, please attach the 4 photo's at the bottom.


Do you currently visit any of these alternative health care providers?
Do you have discomfort or pain in any of the following?
Do you have or had you had any of the following...
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Intake Form: Sales Lead
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Intake Form: Image
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