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Practitioners
Services & Pricing
New Patients & FAQ
Visit
Gift Cards
Booking
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Date of Birth
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Name
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First Name
Last Name
Preferred Pronouns
Occupation
Address
Phone
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Email
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Emergency Contact
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Emergency Contact Phone Number
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Primary health concerns
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Please describe your reason(s) for seeking treatment with us:
The following questions are voluntary but the information gathered helps us treat you holistically. Please answer only what you feel comfortable to share at this time.
Current medications/supplements:
Current or former hospitalizations, surgeries, major injuries, or trauma:
Please list what & when
Health history:
Please select any of the following that you've had or currently have
Addiction
Anemia
Asthma
Bleeding disorder
Cancer
Diabetes
Epilepsy/seizures
Heart disease
Hepatitis A/B/C
HIV+
Long Covid
MS
Osteoporosis
Pacemaker
Stroke
Thyroid disorder
Tuberculosis
Allergies:
Autoimmune disorder:
Please describe where your pain is located on your body:
How severe is your pain?
Please choose a number on a scale of 1 (no pain) to 10 (severe pain)
1 (none)
2
3
4
5
6
7
8
9
10 (severe)
How does the pain feel?
Please choose any that apply:
Burning
Dull
Shooting
Tingling
Sharp
Achy
Stiff
Throbbing
What, if anything, makes the pain better?
What, if anything, makes the pain worse?
Please indicate your energy level over the past 2 weeks:
Choose a number on a scale of 1 (no energy) to 10 (very energetic):
1 (no energy)
2
3
4
5
6
7
8
9
10 (very energetic)
On average, how many hours of sleep do you get per night?
Sleep
Please select all that apply to you:
Difficulty falling asleep
Difficulty staying asleep
Restless sleep
Restless leg syndrome
Vivid/stressful dreams
Not rested upon waking
Emotional & psychological
Please select all that apply to you:
Shy/timid
Irritability/easy to anger
Anxiety/worry
Extreme fear/terror
Considered or attempted suicide
Depression/sadness/cry a lot
Lifestyle
Please select all that apply to you:
Exercise regularly
Eat regularly
Drink alcohol
Drink coffee
Drink more than 60oz of water per day
Smoke cigarettes
Use marijuana/CBD regularly
Use other recreational drugs
Never thirsty
Always thirsty
Prefer hot drinks
Prefer cold drinks
Please list any special diets you adhere to:
Please list any foods you avoid:
Please list any foods you tend to crave:
Please describe what you typically eat for meals:
Breakfast:
Lunch:
Dinner:
Digestion
Please select all that apply to you:
Excessive appetite
Low appetite
Fatigued after meals
Reflux/heartburn/belching
Nausea/vomiting
Gas/bloating
Abdominal/stomach pain
Bowel movement feels incomplete
Constipation
Hemorrhoids
Diarrhea/loose stools
IBS
Urinary
Please select all that apply to you:
Frequent urination
Regularly wake up 2 or more times at night to urinate
Poor bladder control
Burning/pain while urinating
Urination feels incomplete
Frequent UTIs
Kidney stones
Kidney disease
Cardiovascular
Please select all that apply to you:
High blood pressure
Palpitations
Irregular heartbeat
Tight chest
Edema/swelling
Respiratory
Please select all that apply to you:
Frequent colds
Chronic allergies
Asthma
Shortness of breath
Cough
Head/ears/eyes/nose/throat
Please select all that apply to you:
Headaches
Migraines
Jaw pain
TMJ
Teeth grinding
Ringing in ears
Poor hearing
Dizziness
Earache/ear infections
Floaters (spots in vision)
Eye tearing/dryness
Red/itchy eyes
Sinus congestion
Post-nasal drip
Phlegm stuck in throat
Nose bleeds
Mouth/tongue sores
Bad breath
Bleeding gums
Recurrent sore throat
Temperature/perspiration
Please select all that apply to you:
Generally tend to feel hot
Generally tend to feel cold
Cold hands/feet
Feel hot in the afternoon
Hot flashes
Night sweats
Spontaneous sweating
Sweaty palms/feet
Skin/hair
Please select all that apply to you:
Rash/itching/hives
Acne
Dry/brittle hair
Hair loss
Weak/brittle nails
Dandruff/dry scalp
If applicable:
Please select all that apply to you:
Experience PMS
Experience cramps
Fatigued with period
Clots with periods
Endometriosis
Heavy periods
Irregular cycle
Abnormal bleeding
Uterine fibroids
Ovarian cysts
Vaginal dryness
Yeast infections
Low libido
Trying to get pregnant
(May be) pregnant
Have miscarried
Average length of full menstrual cycle:
How many days in between your periods
How many days does bleeding typically last?
Current method of birth control:
Total number of pregnancies:
Thank you! We look forward to meeting you soon.