Congratulations For Taking Action!
Thank you for completing this questionnaire! Your responses will help us better understand your needs so we can serve you at a higher level. After you finish, enjoy a free 15-minute consultation with a pain-relief & body-alignment expert. We look forward to discussing how we can assist you in achieving your wellness goals!
Date
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Month
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Day
Year
Date
Name
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First Name
Last Name
Phone Number
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Area Code
Phone Number
Email
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example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
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Month
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Day
Year
Date
Age
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Gender
Male
Female
As part of our full service to our clients, we do periodic follow ups. Please select the ways you would like us to contact you. (Select all that apply)
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Text
Cell Phone
Email
Other
How did you hear about us? Google search, referral; if from a friend, doctor, coach, trainer, etc., please let us know so we can thank them.
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If you used a Google Search, which words did you use to search for what you were looking for?
Do You Like to Use Social Media to get information on wellness and pain relief? (please select all that apply)
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No, I do not use social media platforms.
Yes, Facebook
Linkedin
Instagram
TikTok
Snapchat
Other
Would you be comfortable with us posting your transformational progress on a social media platform?
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No thank you, I prefer my privacy.
Yes, I would love to use social media to showcase my before and after transformation!
Other
We offer Zoom Call (on-line) coaching services for pain relief, nutrition coaching and in-home personal training. (Select all that apply.)
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I wish to come into your office for all of my transformational sessions.
I would like to come in for my sessions but I also travel a lot. I am open to knowing more about the benefits of doing some sessions on line.
I do not live in the area and cannot come into your office. I would like to benefit from your services by participating in one of your on-line training programs.
Are you in pain? If so, what is the Pain Level from 1-10 ten being the most painful. and How long have you been feeling pain or limitations from your injury or condition?
What would life be like without this pain or limiting condition? Is it limiting you from doing or enjoying things you want to do?
Do you actively participate in any sports or competitive activities? Please list the position you play if you play any team sports.
How would you describe yourself?
Pro or semi-pro athlete
Serious recreational athlete
Youth athlete in school sports
Moderately active
Couch potato
How soon would you want to start a program that has a proven success rate and can help you achieve your desired outcomes (goals and objectives)?
I am ready to start now, the sooner the better!
Within a few weeks.
Within 6 months.
Occupation
Height
Current Weight
Weight 1 year ago
Ideal Weight
Mother's age and health status.
Father's age and health status.
History: Any serious illnesses/hospitalizations/surgeries/limitations? (Please list the dates or your age the time the event took place):
Is using a natural approach to wellness important to you?
What treatments have you tried? Please select all that apply.
Surgery
Physical Therapy (PT)
Chiropractic
Rolfing
Massage
Reiki, or other Energy Work
Acupuncture
Cranial Sacral Therapy
Hypnosis
Meditation
Egoscue Method
Alexander Technique
Nutritionist/Health Coach
Hyperbaric Treatments (HBOT)
Other
What supplements/vitamins do you currently take?
Any known allergies/sensitivities? Are you taking medications for them?
Digestion: (Check if You Experiencing Any On A Regular Basis)
Irritable Bowel Syndrom (IBS)
GERD, Gastro Esophageal Reflux Disease
Burping, Gas, Bloating
Heartburn or Sour Stomach
Constipation
Diarreah
Frequency of bowel movements?
1 time per day
2-3 times per day
A few times per week.
Once a week or less.
History of any of the following conditions?
Have you ever worn braces?
Scoliosis
High or Low Blood Pressure
Heart Condition
Cancer
Diabetes
Parkinson's
MS
Arthritis
Osteoperosis
Respiratory Disorder
Asthma
Epilepsy
Phlebitis
Stress or Nervousness
Other
Are you have or are you being treated for any of the following conditions? (Please check all that apply)
HIV, AIDS
Staff Infection, MRSA
Hepatitis A,B or C
Cold, Flu
Herpes, Shingles
Tuberculosis, TB
COVID-19 or Long COVID
Side effects from COVID Vaccination or Boosters
EBV, Epstein Barr Virus
Please elaborate on any yes answers to the history of conditions above.
What prescription medications do you currently take?
When Is the last time you were on an antibiotic? Name of antibiotic?
Where you ever on antibiotics for an extended period of time (3 months or more)? For what condition? Name of antibiotic?
Are you on hormone replacement therapy (HRT)?
Hormone Replacement Therapy?
What time do you normally go to sleep? What time do you normally wake up?
Do you wake up in the middle of the night? How often? Please explain why: Pain, to pee, etc.
Do you feel rested when you wake up?
Yes, I almost always feel great when I wake up.
Sometimes I feel rested when I wake up.
I feel pretty good once I have my coffee.
I am usually still very tired when I wake up.
Would you like to sleep better?
Yes, I would like to sleep better.
I sleep good so it is not really a concern of mine.
What kinds of things do you like to do to help you relax?
For Woman Only
Next 7 questions:
Are you Pregnant?
Yes
No
Are Your periods regular?
Painful or Symptomatic?
Have you had children? Ages?
Reaching or approaching menopause?
Any abdominal surgeries, C-Section, Lipo. If Yes, any ongoing side effects from the surgery?
Nutrition Information
Please fill out this section even if you are coming in for pain relief because your food choices can affect inflammation, your pain level and how quickly injuries heal.
What do you like to eat for breakfast?
What do you like to eat for lunch?
What do you like to eat for dinner?
Snacks
How much water & other beverages do you drink throughout the week.
Do you crave sugar, coffee, chocolate, cigarettes or other?
Are you currently on diet or a nutrition program?
Have you ever kept a food journal or diary?
What percent of your food is home cooked?
Where do you get the rest from?
Do You own any of the following?
Blender
Juicer
Vitamix, Nutribullet, Nija
Rice Cooker
Crock Pot
Instantpot
What are 1-3 things that you know you can do to improve your health?
Our 12-Session Align the Body and Heal the Pain Program has over a 97% success rate with our clients, in part because we are always improving what we do and how we do it. If you choose to go forward with the program, would you be willing to share your feedback as you are completing the program; stating what you like best and what can be improved to serve you at a higher level?
Yes, I am happy to give feedback.
Yes, but my privacy is very important, only if my name is kept private.
No, I prefer not to offer any feedback.
Is there anything else you would like to share?
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