Looking for the first steps? Start with our 3 minute questionnaire and we’ll provide you with a personalized wellness plan! Survey Are you ready to reclaim your health? Your wellness plan is just that --- YOURS! By providing us your unique experience with wellness, we can create a completely customized plan just for you! All information that you include in the upcoming questionnaire is 100% confidential. We will NEVER share this information without your expressed written consent. What would you prefer?(Required) To complete a centralized intake process where your personal health history is collected and then relayed to the entire team to create a coordinated care plan. To see each individual practicioner I want to engage with individually for their intake process. Are you filling this form in for(Required) you a loved one? Their Name(Required) First Last Age(Required) What is the number one health condition you most want to change?(Required) Physical Pain (back, joints, neck etc) / Numbness/Tingling/Loss of Sensation Sleep Disturbance Digestive Problems Hormone or Reproductive Organ Issues Immune/Autoimmune Conditions Concussions/Head Injury Mental Wellness Cardiovascular Issues Neurological Condition Pre/Post Natal Care Other Check all that apply(Required) Back Pain Neck Pain Shoulder Pain Elbow/Hand/Wrist Pain Hip Pain Knee/Ankle/Foot Pain Face/Head/Jaw Pain (including headaches/migraines) Fibromyalgia Chronic Fatigue Syndrome Other Check all that apply(Required) Insomnia Sleep Apnea Narcolepsy Restless Leg Sleep Walking Other Check all that apply(Required) IBS Crohn’s / Colitis Reflux / Heartburn/ GERD Constipation Diarrhea Hemorrhoids Other Check all that apply(Required) Hypothyroid (low thyroid) Hyperthyroid (high thyroid) Irregular Menstrual Cycle Polycystic Ovarian Syndrome Endometriosis Fertility (male or female) Erectile Dysfunction Menopause Other Check all that apply(Required) Lyme’s Disease Cancer Multiple Sclerosis Lupus Rheumatoid Arthritis Diabetes Hashimoto's Thyroiditis Other Check all that apply(Required) Cognitive Fatigue Headaches Migraines Muscle Tension (neck/shoulder) Post Concussion Syndrome Whip-lash Difficulty Performing Day-to-Day Tasks Other Check all that apply(Required) Anxiety Depression Stress Grief and Loss Relationship Conflicts Low Self-esteem Post Traumatic Stress Disorder Other Check all that apply(Required) Circulatory problems Depression High Blood Pressure Low Blood Pressure Heart Attack Atherosclerosis Stroke Arrhythmia Blood Condition/Disease Congestive Heart Disease Other Check all that apply(Required) Alzheimer's Dementia Parkinsons Disease ALS (amyotrophic lateral sclerosis) Multiple Sclerosis Neuropathy Migraines Other Check all that apply(Required) Nausea Breech/Posterior Babies Induction Milk Supply/Production Lactation Wound Healing/Scar Tissue Repair Post Partum Depression Other Please Specify(Required) How long have you been dealing with this condition?(Required) Acute onset in past 7 days Sub acute 7-28 days 1-3 months 3-6 months 1 year 2-5 years 5-10 years More than 10 years Please tell us more about your symptoms Do you have any other conditions you’d also like to address?(Required) Yes No What is the number two health condition you most want to change?(Required) Physical Pain (back, joints, neck etc) / Numbness/Tingling/Loss of Sensation Sleep Disturbance Digestive Problems Hormone or Reproductive Organ Issues Immune/Autoimmune Conditions Concussions/Head Injury Mental Wellness Cardiovascular Issues Neurological Condition Pre/post Natal Care Other Check all that apply(Required) Back Pain Neck Pain Shoulder Pain Elbow/Hand/Wrist Pain Hip Pain Knee/Ankle/Foot Pain Face/Head/Jaw Pain (including headaches/migraines) Fibromyalgia Chronic Fatigue Syndrome Other Check all that apply(Required) Insomnia Sleep Apnea Narcolepsy Restless Leg Sleep Walking Other Check all that apply(Required) IBS Crohn’s / Colitis Reflux / Heartburn/ GERD Constipation Diarrhea Hemorrhoids Other Check all that apply(Required) Hypothyroid (low thyroid) Hyperthyroid (high thyroid) Irregular Menstrual Cycle Polycystic Ovarian Syndrome Endometriosis Fertility (male or female) Erectile Dysfunction Menopause Other Check all that apply(Required) Lyme’s Disease Cancer Multiple Sclerosis Lupus Rheumatoid Arthritis Diabetes Hashimoto's Thyroiditis Other Check all that apply(Required) Cognitive Fatigue Headaches Migraines Muscle Tension (neck/shoulder) Post Concussion Syndrome Whip-lash Difficulty Performing Day-to-Day Tasks Other Check all that apply(Required) Anxiety Depression Stress Grief and Loss Relationship Conflicts Low Self-esteem Post Traumatic Stress Disorder Other Check all that apply(Required) Circulatory problems Depression High Blood Pressure Low Blood Pressure Heart Attack Atherosclerosis Stroke Arrhythmia Blood Condition/Disease Congestive Heart Disease Other Check all that apply(Required) Alzheimer's Dementia Parkinsons Disease ALS (amyotrophic lateral sclerosis) Multiple Sclerosis Neuropathy Migraines Other Check all that apply(Required) Nausea Breech/Posterior Babies Induction Milk Supply/Production Lactation Wound Healing/Scar Tissue Repair Post Partum Depression Other Please Specify(Required) How long have you been dealing with this condition?(Required) Acute onset in past 7 days Sub acute 7-28 days 1-3 months 3-6 months 1 year 2-5 years 5-10 years More than 10 years Please tell us more about your symptomsPlease click "next" to proceed Do you have any other conditions you’d also like to address?(Required) Yes No What is the number three health condition you most want to change?(Required) Physical pain (back, joints, neck etc) / Numbness/Tingling/Loss of Sensation Sleep Disturbance Digestive Problems Hormone or Reproductive Organ Issues Immune/Autoimmune Conditions Concussions/Head Injury Mental Wellness Cardiovascular Issues Neurological Condition Pre/post Natal Care Other Check all that apply(Required) Back Pain Neck Pain Shoulder Pain Elbow/Hand/Wrist Pain Hip Pain Knee/Ankle/Foot Pain Face/Head/Jaw Pain (including headaches/migraines) Fibromyalgia Chronic Fatigue Syndrome Other Check all that apply(Required) Insomnia Sleep Apnea Narcolepsy Restless Leg Sleep Walking Other Check all that apply(Required) IBS Crohn’s / Colitis Reflux / Heartburn/ GERD Constipation Diarrhea Hemorrhoids Other Check all that apply(Required) Hypothyroid (low thyroid) Hyperthyroid (high thyroid) Irregular Menstrual Cycle Polycystic Ovarian Syndrome Endometriosis Fertility (male or female) Erectile Dysfunction Menopause Other Check all that apply(Required) Lyme’s Disease Cancer Multiple Sclerosis Lupus Rheumatoid Arthritis Diabetes Hashimoto's Thyroiditis Other Check all that apply(Required) Cognitive Fatigue Headaches Migraines Muscle Tension (neck/shoulder) Post Concussion Syndrome Whip-lash Difficulty Performing Day-to-Day Tasks Other Check all that apply(Required) Anxiety Depression Stress Grief and Loss Relationship Conflicts Low Self-esteem Post Traumatic Stress Disorder Other Check all that apply(Required) Circulatory problems Depression High Blood Pressure Low Blood Pressure Heart Attack Atherosclerosis Stroke Arrhythmia Blood Condition/Disease Congestive Heart Disease Other Check all that apply(Required) Alzheimer's Dementia Parkinsons Disease ALS (amyotrophic lateral sclerosis) Multiple Sclerosis Neuropathy Migraines Other Check all that apply(Required) Nausea Breech/Posterior Babies Induction Milk Supply/Production Lactation Wound Healing/Scar Tissue Repair Post Partum Depression Other Please Specify(Required) How long have you been dealing with this condition?(Required) Acute onset in past 7 days Sub acute 7-28 days 1-3 months 3-6 months 1 year 2-5 years 5-10 years More than 10 years Please tell us more about your symptomsPlease click "next" to proceed Have you sought help for your initial complaint before?(Required) Yes No What have you tried?(Required) Surgery Medications Physiotherapy Occupational therapy Massage therapy Osteopathy Chiropractic Naturopathic medicine Supplements Acupuncture Traditional chinese medicine Ayurveda Counselling/Therapy/Psychotherapy Pelvic Floor Physiotherapy Functional Nutrition Herbal Medicines Topical Skincare Treatments Other Please Specify(Required) Is there anything you are too uncomfortable/absolutely unwilling to try to address this issue?(Required) No Surgery Medications Physiotherapy Occupational therapy Massage therapy Osteopathy Chiropractic Naturopathic medicine Supplements Acupuncture Traditional chinese medicine Ayurveda Counselling/Therapy/Psychotherapy Pelvic Floor Physiotherapy Functional Nutrition Herbal Medicines Topical Skincare Treatments Other Please Specify(Required) Please click "next" to proceed When creating a plan for you that will actually work we need to understand how much time you can devote to resolving this. Our goal is to get you the best results in the fewest number of treatments to ensure your issue is resolved and stays resolved.I can commit to:(Required) More than 1 appointment per week 1 appointment per week 1 appointment every other week 1 appointment per month 1 appointment every 3-6 months I can commit to whatever it takes to see results Do you intend to use extended health benefits to cover your treatments?(Required) Yes No What do you have coverage for (this will help us make a recommendation by finding a practitioner that can address your needs but also is covered under your plan) ?(Required) Physiotherapy Massage therapy (RMT) Osteopathy Acupuncture Naturopathic medicine Chiropractic Occupational therapy Counselling (social worker) Counselling (psychotherapy) Counselling (psychologist) Other (fill in blank) (Required) Anything else you’d like to share with us?Name(Required) First Last Phone(Required)Email(Required) Relax. Reset. Recharge.
