WORK WITH ME.
This is suitable for someone that is currently dealing with pain or an issue that is limiting them in some way. Please fill out the form as detailed as possible. This gives me a better understanding of what you want to achieve by working with me.
Please enter your Full name
*
First Name
Last Name
E-mail address
*
example@example.com
Phone number
What is your main reason for wanting to work with me? ( Briefly describe main problem an indicate and areas of concern )
If not mentioned previously, do you experience any of the follow symptoms?
Pins and needles / Numbness
Weakness or loss of strength
Fatigue
Limited range of motion
Hesitation of a position or movement
Redness / swelling
Have you worked with a health practitioner previously for this particular concern?
Do you have any goals you would like to achieve by working with me?
Please list any previous injuries / illnesses or current health problems.
What are you expecting to gain from this consult?
What would you like to be doing that your current situation is stopping you from?
On a scale of 1-10 ( 1=no stress, 10 = extremely stressed) What has your stress levels been like recently?
Please list any medication or supplements you are currently taking:
Please tick if you have experienced problems with the following
Balance / Co ordination
Dizziness or vertigo
Mental health issues
Diabetes or high blood pressure
Heart / vascular problems
Night pain
Bladder dysfunction
Is there any other information you would like to share?
How did you hear about us?
Instagram
Word of mouth
Facebook
Other
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