New Clients
Intake Form
Full Name *
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Phone Number *
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Email Address *
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Street Address
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Age *
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Physician's Name and Phone Number *
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Are You Currently Working?
What is Your Occupation?
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How Did You Hear About Wild Radiance?
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What is the Primary Issue That Motivated You to Seek Out Services From Us?
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What is Your Secondary Complaint?
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When Did Your Symptoms Begin?
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How Did Your Symptoms Begin? For Example, Did they Begin Because of an Accident or Trauma, or did they Begin Without a Known Cause?
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What Activities INCREASE Your Symptoms?
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What Activities DECREASE Your Symptoms?
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List Any Other Modalities or Therapies You Have Tried for This Condition and Describe Their Effectiveness:
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Past Medical History: Please List all Your Surgeries, Traumas, Accidents, or Other Conditions and the Years They Occurred:
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Are You Currently Pregnant or is There A Possibility You May Be Pregnant?
Please List All Current Medications and Supplements as Well As Dosage and Reason for Taking Them:
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Please Rate on a Scale From 1-10 How Much Emotional Stress Your Symptoms or Condition Has Caused You, With 1 Being Very Little and 10 Being The Worst You can Imagine.
List All Your Treatment Goals. Be as Specific as Possible (eg. I want to walk to work without back pain, etc):
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Please Share Anything Else You Think I Need To Know Before We Begin Working Together:
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