Thank you for scheduling your consultation. Please fill out this form as honestly as possible.
How did you hear about us?*
If referred by a friend, who may I thank?*
Please indicate which of the following symptoms you have experienced?*
If you know, were there any issues with your birth?*
If you remember, did you have any major falls, accidents, or trauma as a child?*
Have you had any major stress, trauma, or injuries as an adult?*
Do you use alcohol, drugs, nicotine, etc.?*
In what position do you generally sleep?*
If you did not have any of the above issues, what activities would you be doing?*
Where do you currently work and what do you do there?*
On a scale of 1-5, how happy are you with your life right now? 1-not at all, 5-extremely happy*
On a scale of 1-5, how stressed are you currently in your life? 1-not at all, 5-extremely stressed*
Why are you coming to see me? What are you hoping to get out of this experience?*
Anything else you want me to know?*