Thank you for scheduling your consultation. Please fill out this form as honestly as possible. Please use the same email you used when booking your appointment so everything stays connected.
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?*
What sports, if any, did you play in school or 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?*