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Client Forms

Here are all the Client Forms needed for our New Clients as well as our Established Clients.

New Clients Start Here:

Welcome to 21st Century Total Wellness! If you’re ready to get started as one of our clients, there are four steps to follow:

1. Legal Disclaimer & Scheduling Policy

Note: Please do this step first – this must be fully completed prior to placing orders and before consultation services can be rendered.

2. FirstLine Therapy (FLT) Health History

The second step is to provide us with a FirstLine Therapy (FLT) Health History. There are two ways this can be done:

Online Submission of Health History
Download PDF of Health History Form — this you will fill out and fax or mail to our office.

3. Health Appraisal Questionnaire

The third step is to fill out our Health Appraisal Questionnaire. Due to the length of this particular form, we have broken the online submission option into sections.

On this section you also have the option to do an online submission or to download the PDF below to fill it out and fax or mail it to our office.

Please complete all sections that apply:

  • Parts 1-5 (Everyone fills out this section.)
  • Parts 6-10 (Everyone fills out this section.)
  • Parts 11 (Male clients only fill out this section.)
  • Parts 12 (Female clients only fill out this section.)

Download PDF of Health Appraisal Questionnaire — this you will fill out and fax or mail to our office.

Client Second Step:

FLT Health Profile

Online Submission Option
Download PDF of FLT Health Profile

Follow Up Client Section (password required)

FLT Follow up Questionnaire

Online Submission Option
Download PDF of FLT Follow up Questionnaire

ND Section (password required)

FLT Script Pad (Formerly FirstLine Therapy Therapeutic Lifestyle Program)

Online Submission Option
Download PDF of FLT Script Pad

FLT Goal Sheet (Formerly FirstLine Therapy Establishing Health Goals)

Online Submission Option
Download PDF of FLT Goal Sheet

FLT Plan of Care (POC) (Formerly FirstLine Therapy Individual Program Plan)

Online Submission Option
Download PDF of FLT Plan of Care (POC)

FLT Menu Plan Worksheet

Online Submission Option
Download PDF of FLT Menu Plan Worksheet

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