Intake

*All Appointments are in Central Standard Time.*

How did you hear about us?

Read the Book

Referral

Other


On a scale of 1-10 How badly do you want to get better?

Are you willing to do anything in order for that to happen (within reason)?

What would your life look like if you were able to get better?

Do you understand that once the inflammation is resolved and stressors are balanced, there will be additional work to do (sometimes extensive) on your part related specifically to retraining thought processes, behaviors and patterns that have developed?

Yes

No


Are you willing to do this work?

Yes

No


What is your current Diagnosis?

What are your current medications?

Current Supplements?

Have you seen physicians, psychiatrists, other providers for these issues?

What was the general consensus?

What do YOU believe are the issues?

What is your current lifestyle?

Healthy

Moderate

Unhealthy


Do You Work out?

Yes

No


Do You Eat Healthy?

Yes

No


What does your diet consist of primarily?

Do You Smoke?

Yes

No

Do You Drink?

Yes

No

Do You Use Drugs?

Yes

No

History of infections and ages they occurred:

Current Symptomatology: (include physical, psychiatric, addiction issues)

Past Symptomatology: (include physical, psychiatric, addiction issues)

Surgeries?

Mother’s Diagnosis
A little bit about your mother

Father’s Diagnosis
A little bit about your father

Any other relevant information you can provide about other family members we may need to know including but not limited to: Autoimmune diagnosis, psychiatric symptoms diagnosed or not, history of addiction, abuse etc.

Are you pregnant?

Yes

No

Possibly