Pre-Assessment Consultation Form

Medication, Chemical & Stimulant Free Wellness Vitality & Optimal Health

R.E.S.T.

R.E.P.A.I.R.

T.H.R.i.V.E.

Pre-Assessment Consultation Form

Medication, Chemical & Stimulant Free Wellness Vitality & Optimal Health

Services

Pre-Assessment Consultation Form

Feel free to contact us with any questions or concerns. You can use the form on our website or email us directly.

We appreciate your interest and look forward to hearing from you.

Name*

Last name*

Your email*

May we follow up your form submission with a phone call?*

Yes

No

Contact Phone Number:*

How would you rate your overall health currently?*

Excellent

Good

Fair

Poor

What are your top 2 health concerns or goals for this consultation?*

Are you recovering from a recent surgery or injury?*

Yes

No

If yes, please briefly describe and include the date:

Please list any current medications or supplements:*

ENERGY & RECOVERY - How would you describe your energy levels throughout the day?- *

Consistently high

High in the morning, decreases in afternoon

Moderate with ups and downs

Generally Low

How would you rate your sleep quality?*

Excellent

Good

Fair

Poor

How would you describe your recovery after physical activity?*

Rapid Recovery

Normal Recovery

Slow

What types of physical activity do you typically do?*

What is your typical stress level (1-10, with 10 being highest)?*

Health Indicators - Please check any symptoms you regularly*

"Brain fog" or difficulty concentrating

Muscle weakness or easy fatigue

Extreme exhaustion after activity

Headaches

Slow recovery from illness or injury

Digestive issues

Shortness of breath with mild exertion

Pain or discomfort

CARE GIVER STATUS- Are you currently a caregiver for someone else?*

Yes

No

If yes, approximately how many hours per week?

CONSULTATION FOCUS - What specific areas would you like to focus on during our consultation? (Check all that apply)*

Enhancing recovery from surgery/injury

Improving energy levels

Better sleep quality

Athletic/physical performance

Pain management

Stress reduction

Caregiver support

Long COVID recovery

Cellular/mitochondrial health

Other:

Have you tried other approaches to address your health concerns?*

Yes

No

If yes, please briefly describe:

Is there anything else you'd like us to know before your consultation?

Thank you for completing this assessment. Your responses will help us tailor your consultation to your specific needs and goals. We look forward to working with you!

Privacy Notice: All information provided will be kept confidential and used only for the purpose of customizing your consultation experience.

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