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First Name *

Last Name *

Date of birth

Email *

Phone *

Occupation

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Health conditions/concerns *

What symptoms are affecting your life the most? *

What symptoms are affecting your life the most?

When did your symptoms or conditions begin?

What therapies have you tried

Are you pregnant?

Yes

Not applicable

Do you have pacemaker?

Yes

Any medical conditions or injuries we should be aware of?

Which services are you most interested in? (Check all that apply):

Are there any therapies or approaches you’re not comfortable with or would prefer to avoid?

If your health improved significantly, what activities or experiences would you love to enjoy again?

Have more energy and feel like myself again

Reduce or eliminate daily pain

Sleep better and wake up refreshed

Get back to work or hobbies I enjoy

Rebuild my immune system and resilience

Be more present for family and loved ones

Enjoy travel or social activities again

Restore appetite, digestion, or weight balance

Feel confident in my body and health choices

Regain a sense of calm, confidence, and hope

On a scale of 1 – 10, how committed are you to making lifestyle changes to improve your health?

When would you like to begin?

Would you have a budget in mind?

How did you hear about us?

Feedback on this form or anything else you would like us to know

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