Documents & Forms
following documents and forms are used in this office to allow us to
better assist you in meeting your needs. These files can be best viewed
using Adobe Reader; which can be obtained free at Adobe.com.
For your convenience you may complete these forms online, print out and
bring to your appointment. Completing the Initial Intake Form before
your first visit will save some time, as well.
of the other documents and/or forms below provide additional
information which may assist the practitioner in developing a more
comprehensive healthcare program for your particular needs. If you need
to print out and/or complete any of the additional documents or
forms, you will be notified when you schedule your appointment.
Initial Intake Form- This form
is used to provide the clinician with all of the particulars of
your current concern. Please be as complete as possible when filling out
this form. During the intake the clinician will use this information as
a framework for discussing your problem.
Low Level Laser Consent Form- This form is used to authorize the clinician to use the Low Level Laser as an adjunctive treatment modality in your care. Low level laser therapy has been used for years
in rehabilitation to promote healing while reducing pain. Treatments are applied to specific body points along various acupressure
meridians; these points are mostly on the ears, face, hands and arms. The low
level laser, as it is used here, works much like acupressure with the added
benefit of enhanced stimulation of the identified points while helping to reestablish
and unblock the flow of negative energy within the body.
Nutrition Symptom Survey-
This questionnaire is designed to assess your symptoms in light of your
overall nutrition status. This form is not used as a sole means of
providing a clinical diagnosis. When provided with a thorough clinical
evaluation, however, it can be very helpful in identifying any
underlying nutritional deficiencies or organ stress which may be
benefited through various supplements.
Food Intake, Activity & Emotion Journal-
This is a log for recording all of the different foods and drinks that
you are ingesting for a given period. You can also record the various
types of physical activity and exercise for which you are participating.
Often we will request this information to better understand your
current energy balance. We usually ask for you to maintain this log for a
period of seven (7) days. You will want to be as accurate as possible
while recording the requested information so we can have a better
analysis of your nutritional and exercise needs.
Bach Flower Symptom Survey- This
questionnaire is used to as a general assessment tool for your overall
emotional state. Since much of our health is manifested in the degree of
stress we are under, it is helpful for the clinician to have a good
picture of this aspect of your health. If necessary we may recommend
Bach Flower Remedies or other emotional support modalities for any
issues that we may feel would otherwise hinder your full recovery.
Par-Q and You-
This is a good basic screening tool to assess if physical activity or
exercise is appropriate to your current health status. "Yes" responses
to the survey should prompt you to seek further clearance from you
primary care provider before undertaking any exercise program.
Finding the Time-
This tool is helpful in helping those individuals who find it hard to
find time to exercise or if at the end of the day they are questioning
where their time went. It is especially useful to see how you are
spending your day and how best to fit in one more thing... exercise.Better Breathing Exercise-
This is the breathing exercise that was (or will be) presented during
your session. Breathing is essential for life. When we aren't breathing
well or completely (filling the lungs with life giving oxygen) we will
not be able to focus our attention as well as we should. Remember, this
is just but one tool that will help you in the quest to achieve your
goals; use it every day and during times of increased stress to regain
control and focus.