Wellness Consult Registration

Thank you for reaching out to learn more about how we might help you "find YOUR way" to less pain, and greater vitality. All care here at Discover Yoga & PT is personalized and holistic. Please take a moment to provide us with some information prior to our call so that we can help you decide if we are the best provider to help you, and, if so, which of our spectrum of services is the best place to start.

First name

Last name

Phone

Birthday

Month

Day

Year

Are you interested in virtual or in-person care?

Virtual

In-Person

How did you hear about us?

What are you looking for help with?

How long have you been dealing with this?

Why now? What is your driving reason for seeking help now?

What are your goals?

Have you sought care for this issue elsewhere?

Yes

If yes, who have you seen, are you currently under their care and what was / has been the outcome?

Do you have any significant medical conditions that you are currently receiving care for? (please list)

How would you rate your overall health?

Poor

Fair

Good

Excellent

Please rate your satisfaction with your sleep on a scale of 1(awful) - 10 (perfect, no issues)

Please rate your satisfaction with your diet from (1-10)

Please rate your satisfaction with your physical fitness / recreation / exercise from 1-10.

Please rate your current stress level on a scale of 1-10?

Please rate the highest level of pain you have experienced in the last 2 weeks from 1-10?

Please list any medications you are currently taking.

In general, what are the best days / times for you to meet?

Wellness Consult Registration

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