Additional Health History Form

Congratulations on being accepted into the Rinehold Signature Program! This Health History form is optional (but preferred!) for those accepted into the program

Step 1 of 4


General Information

Please give a brief description of each.
Include anyone who currently lives in your home.
Does your household eat dinner together?
Please list all that you can think of.
Please include the reason for each avoidance and the duration you've been avoiding these foods.