Dr. Michael Scimeca Entrance Form
Please fill out the form below.
Name
Last Name
Legal First Name
Preferred Name
Name you choose to be called
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Email
example@example.com
Occupation
Date Of Birth
Example: 11/07/1980
Age
Sex
Marital Status
Number of Children
Names and Ages of People Living With You
How did you hear about Dr. Michael? / Who referred you?
Which of the following choices most accurately describes you today?
I am here for: (Choose the ONE Best Answer)
My Health
My Relationship
My Life
My Child
My Career
Concerning my health, I am looking to: (Choose One Only)
Regain it
Maintain it
Improve it
Not A, B, or C
Concerning my quality of life, I looking to: (Choose One Only)
Regain it
Maintain it
Improve it
Not A, B, or C
What are some of your specific goals that motivated you to be here today?
Choose the titles below of what you are currently doing:
Prescription Drugs
Non-Prescription Drugs
Herbs
Homeopathic
Remedies
Supplements
Provide specific names of what you’re taking and why you are taking them
Are you following a special diet? If yes, explain.
Do you drink coffee or tea? If yes, how much?
Do you smoke? If yes, how much?
Do you drink alcohol? If yes, how much?
Hours of sleep per night:
Describe your quality of sleep: (Excellent / Good / Average / Sporadic / Poor)
List any history of significant emotional trauma (provide dates):
List any history of significant physical trauma (falls, accidents, injuries, etc.) (provide dates):
List any history of chemical trauma (exposure to toxic substances and/or any known food allergies and hypersensitivities):
List any history of hospitalizations or surgeries (provide dates):
Choose ALL that you have done in the past:
Coaching
Counseling
Catalyst
Chiropractic
Exercise
Massage
Meditation
Physical Therapy
Yoga
Choose ALL that you are currently doing:
Coaching
Counseling
Catalyst
Chiropractic
Exercise
Massage
Meditation
Physical Therapy
Yoga
What other strategies do you use for taking care of yourself (for your health, attitude, wellbeing, quality of life, personal growth, etc.)?
On a scale of 0-100, how would you grade your overall: Physical State?
On a scale of 0-100, how would you grade your overall: Mental State?
On a scale of 0-100, how would you grade your overall: Emotional State?
What else should Dr. Michael know to help you be successful in achieving your goals? (Please include ANY information that may help him better understand and serve you.)
STATEMENT OF OBJECTIVE / AGREEMENT:
The purpose of this side of the form is to state clearly the objectives of the services Dr. Michael provides. Initial each statement in the space provided to the left to indicate your understanding and acceptance, which includes the obligations you have to yourself.
FOR THE PARENT OR GUARDIAN OF A MINOR CHILD FOR WHICH THIS FORM IS BEING COMPLETED:
Signature
*
Submit
Should be Empty: