Current Medications (Include over the counter, supplements, vitamins & herbs)
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How Did You Find Us?
I Acknowledge: Payment is due at time of service. No-shows and cancellations with less than 24 hours notice will be charged $30 for treatments, $40 for new patient intakes. *
Print Name and Date
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What are your health goals? And why is this important to you?
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For what problems are you currently seeking treatment? Rate the severity of each on a scale of 1-10, 1 = not bad at all, 10= the worst imaginable
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What impact are your symptoms currently having on your life? What are they preventing you from doing? Why is this important to you?
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What methods have you tried in the past to remedy these problems and how did these work for you?
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What roadblocks or challenges are stopping you from getting where you want to go? Put a *** on the biggest one.