Intake Assessment
New Client Questionnaire
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Email *
Phone number *
First Name *
Last Name *
Birthdate *
MM
/
DD
/
YYYY
Main complaints: *
How long have you suffered with this problem *
Any other complaints:
Would you like improvement with any of the following?
What have you tried doing to resolve this problem that DID NOT work?
Have you become discouraged or stressed about handling this problem?
How does this problem interfere with the following areas in your life?
Work:
Family:
Hobbies:
Life:
When it's at it's worst, how much older does this make you feel?
Do you know how this problem may have started?
What effect does this have on your body functions? *
Are you here visiting us to: *
How have you taken care of your health in the past? *
Required
How did the previous methods work for you?
What are you afraid this might be or will be affecting without change? Select all that apply.
Are there any health conditions you are afraid this might turn into? Select all that apply.
Where do you picture yourself being in the next 3-5 years if this problem is not taken care of? Please be specific. *
What would be different or better without this problem? Select all that apply. *
Required
If you were to sit down and discuss your life 3 years from now and look back at today, what would have to happened for you to be happy with your progress? (Please take your time and don't sell yourself short! Include anything that is part of your happiness, whether health, family, work, finances, travel, marriage or bucket list.) *
What potential barriers do you foresee that would prevent these things from happening? *
Do you feel it is possible to eliminate or prevent these potential barriers? *
What are your strengths that will enable you to accomplish your goals? *
How important is it for you to resolve your health concerns? *
Not important
Very important
Do you feel that you are coachable and would enjoy a mentor in helping you? *
Not important
Very important
Are you prepared to make the appropriate lifestyle changes that may be necessary in order to achieve your goals? *
Not important
Very important
Please complete form prior to your scheduled appointment.
Thank you!!
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