Date of Birth

Email Address

What is your primary reason for seeking care?

What was the intial cause?

When did it begin?

What makes it worse & or better?

What have you done about this?

What are your health goals?

List any past or future surgeries

List any significant trauma - When did they occur? (auto accident falls emotional sexual etc )

List exercise and sports activities you have been or are currenlty involved in

Female Concerns - Date of last menstruation?

Female Concerns - Is your cycle regular?

Female Concerns - Is your cycle painful?

Female Concerns - Have you ever been pregnant?

Female Concerns - Birth control? - If so how long?

Do you have any allergies? If so what types and how often?

Do you take supplements? If so what types and how often?

Do you take medication? If so what types and how often?

DISCLOSER

All records, reports, notes, compilations, or other recorded matter, and copies or reproductions thereof relating to the PROPRIETARY INFORMATION and DISCLOSER’s operations, activities, or business, made or received by RECIPIENT during any discussions with DISCLOSER, are and shall remain DISCLOSER’s exclusive property. Immediately upon request from DISCLOSER, RECIPIENT shall deliver to DISCLOSER all written and tangible material in RECIPIENT’s possession belonging to DISCLOSER or incorporating any PROPRIETARY INFORMATION.