Please Complete in Advance of Your Consultation

By providing this background information now, we'll be able to focus your initial consultation on whatever matters most to you.

Your Contact Information
Birth Information
Purpose
Health Status

How would you rate your current state of health?

Very
Poor
Poor Fair Fairly
Good
Good Very
Good
Excellent
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Do you agree with the following statement?

Stress is a big problem for me.

Strongly
Disagree
Disagree Somewhat
Diagree
Neutral Somewhat
Agree
Agree Strongly
Agree
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Diet

Use the <enter> key to make a new row after each entry.

Do you agree with the following statement?

I love to cook.

Strongly
Disagree
Disagree Somewhat
Diagree
Neutral Somewhat
Agree
Agree Strongly
Agree
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Daily Routine
Orientation of Home

The easiest way to assess orientation is to google your address and check a map.

Social Situation
Health History

Your Gender Identity

Units of Measurement for both Weight and Height

Women's Reproductive
Comments

Read This Before Submitting the Form

You will get a confirmation screen with results and an email summary if submission is successful.

On some devices, this form may fail to submit without an error message to help you fix the problem. If that happens, make sure you answered every item including those with radio buttons.. This is the only problem you can encounter.

security phrase

If the Security Phrase is rejected, check to make sure your auto-fill, auto-correct did not incorrectly capitalize the first letter or perpetuate an extra space before or after. On Apple devices you can hit the shift key to select lower case when starting the passphrase or toggle off Auto-capitalization under general settings for keyboard.