Full Name

Email Address

Phone Number

Please describe yourself? (There is no wrong answer here.)

What is your occupation?

Do you currently drink alcohol? (Y/N)

Do you currently smoke? (Y/N)

Do you have any other medical conditions? (It's OK if you do, but we need to know about them.)

Are you currently taking any medication? (Which medications and what are they for?)

On a scale from 1-10 (1 = Horrible 10 = Beyond Exceptional) where would you rank your Health (Overall in both the way you look and Feel)?

What are you willing to do to get PAIN FREE and stay pain free? (Check all that apply)
Come and get treatment.Do a home training program.Meditate.Change your diet.Do an audit of your environment.Create daily rituals that reduce stress.

Where is the pain and what does it feel like?

How long have you had this pain?

Have ever been treated for it? By whom and when?

What were the results of those treatment(s)?

What has worked in the past?

What hasn’t worked in the past?

What will your life be like if you don’t get rid of this pain?

What could your life be like if you were PAIN FREE? What would you do and how would you feel?

What hasn’t worked in the past?


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