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 *
Your answer
Phone Number *
Your answer
Your Age
Your answer
Briefly describe your reason for seeking Middleway treatment: *
Your answer
When and how did this begin? *
Your answer
What makes it feel better?
Your answer
What makes it feel worse?
Your answer
Have you seen a Physician for this complaint? *
If you did see a Physician for this, what was the diagnosis?
Your answer
What medications, if any, are you taking at this time?
Your answer
Have you seen a Physical Therapist for this complaint? *
If you have seen a Physical Therapist, was the treatment effective?
If you have seen a Physical Therapist, are you still practicing the exercises they gave you?
Have you seen a Chiropractor for this complaint? *
If you have seen a Chiropractor for this, was it effective?
Have you seen a Massage Therapist for this complaint? *
If you have seen a Massage Therapist for this, was it effective?
What other types of treatment have you received?
Your answer
What other medical conditions do you have now or have you had in the past?
Your answer
How often do you exercise? *
Never
Days a week
Briefly describe the kinds of exercise that you do:
Your answer
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:
Your answer
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:
Your answer
A copy of your responses will be emailed to the address you provided.
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