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We may have a few additional questions to ensure we can provide the best possible care for you.

Name

Phone - Mobile

Zip Code

Date of Birth

Referred By

What is your preferred form of exercise?

Strength and Conditioning (with weights)

Body Weight Exercises

Crossfit

HIIT

Running

Cycling

Martial Arts

Yoga/Pilates

Swimming

Other

If you chose Other (please describe)

What percentage of your exercise is cardio-based? (running, cycling, etc)

Please rate your level of physical conditioning/muscle mass:

None

Mild

Moderate

Well Conditioned

Please Describe your typical diet:

Are you willing to significantly modify your diet? (please note that best results are had in those who consume collagen in their diets. Vegetarians tend to get poorer outcomes.) 5 (very willing) 1 (very unwilling)

In order to improve your health, are you willing to take several nutritional supplements each day? 5 (very willing) to 1 (very unwilling)

Are you willing to have periodic lab tests to assess your progress?

Have you ever been diagnosed with fibromyalgia or any chronic pain syndromes?

Yes

Do you understand that there is not a "one-shot-wonder" treatment and that multiple visits/treatments/porcedures may be necessary to resolve your issue?

Yes

Are you aware that all visits and treatments are payment at the time of service and we do not bill Insurance at this office?

Yes

How supportive will the people in your household will be to major changes in your time/behavior and allocating financial resources to restore your health? 5 (very supportive) to 1 (very unsupportive):

What are your top three health concerns?

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