Assesment Form

All programs provided by Pūr Life are for use in healthy subjects and are not intended as a substitute for the advice and care of your physician. As with all new diet and nutrition regimens, the program described at Pūr Life should be followed only after first consulting with your physician to make sure it is appropriate for your individual circumstances. Pūr Life programs are not intended for the diagnosis or treatment of any disease or conditionPūr Life does not make any representation or warranty that any program is effective for the treatment of any disease or condition. Certain Pūr Life programs may have risks for side effects that are reviewed with the participant at the time of initial service. Pūr Life is not the manufacturer of any of the devices or nutrition products that are used by Pūr Life and Pūr Life makes no representation or warranty, and disclaims all liability, with respect to their operation or usage. The owners, shareholders, and employees of Pūr Life expressly disclaim responsibility for any adverse effects that may result from the use or application of our programs, treatments or consumption of nutritional products sold by Pūr Life. Certain services arranged at Pūr Life are required to be performed by licensed professionalsWithin the State of New York, all services that are required to be performed by licensed nurses are provided at Pūr Life by licensed nurses working under the control and supervision of a licensed nurse practitioner. Nurses and nurse practitioners performing services at Pūr Life are not employees of Pūr Life and are independent professionals. 


   

HEALTH MAINTENANCE

   

MEDICAL HISTORY

To all questions answered ‘yes’, write a brief explanation.

   

SYMPTOMS

For each question please check yes or no.

   

DO YOU HAVE...

   

CHRONIC ILLNESSES

Assesment Form

We take your privacy very seriously. This assessment form is only reviewed by Dr. Ronnie Deluz or Dr. Tomas Redner or another licensed medical professional. Please fill this out prior to your first visit.

All clients must fill this out prior to their first treatment.


   

HEALTH MAINTENANCE

   

MEDICAL HISTORY

To all questions answered ‘yes’, write a brief explanation.

   

SYMPTOMS

For each question please check yes or no.

   

DO YOU HAVE...

   

CHRONIC ILLNESSES