Middleway Method Physical Analysis Intake Form
Use this form to begin your Physical Analysis. After I receive your completed form, I will contact you within 72 hours to schedule your free 30-minute assessment.

During your analysis, I will review your health history and your current symptoms, and learn about your specific needs and preferences.

Then, I will create a personalized treatment plan that includes hands-on Therapeutic Relaxation, Clinical Treatments, Therapeutic Nutrition and Fitness, and referrals to other health care professionals.
Email address *
Full Name *
Phone Number *
Your Age
Briefly describe your reason for seeking Middleway treatment: *
When and how did this begin? *
What makes it feel better?
What makes it feel worse?
Have you seen a Physician for this complaint? *
If you did see a Physician for this, what was the diagnosis?
What medications, if any, are you taking at this time?
Have you seen a Physical Therapist for this complaint? *
If you have seen a Physical Therapist, was the treatment effective?
Clear selection
If you have seen a Physical Therapist, are you still practicing the exercises they gave you?
Clear selection
Have you seen a Chiropractor for this complaint? *
If you have seen a Chiropractor for this, was it effective?
Clear selection
Have you seen a Massage Therapist for this complaint? *
If you have seen a Massage Therapist for this, was it effective?
Clear selection
What other types of treatment have you received?
What other medical conditions do you have now or have you had in the past?
How often do you exercise? *
Never
Days a week
Briefly describe the kinds of exercise that you do:
How often do you eat more than one cookie equivalent of refined white sugar per day? *
Never
Days a week
How often do you drink more than one cup coffee or caffeinated soda per day? *
Never
Days a week
How often do you drink more than one alcoholic beverage per day? *
Never
Days a week
How many hours on average per night do you sleep? *
Hours
Hours
How many glasses of pure water do you drink per day, on average? *
How often do you do delightful, stress-relieving activities? *
Never
Days a week
Briefly describe the delightful, stress-relieving activities that you do:
Completing this questionnaire so far, you can see that getting adequate exercise, sleep, hydration and enjoyment, and limiting sugar, caffeine and alcohol intake are essential for healthy tissue regeneration (healing). Knowing this, how willing are you to make substantive lifestyle changes where necessary? *
Unwilling
Totally enthusiastic
Please use the space below to ask questions and share important information that was not covered in this questionnaire:
A copy of your responses will be emailed to the address you provided.
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