INTAKE FORMThis form helps us to best serve you. Thank you, and please let us know if you have any questions! Part 1 : Basic Information Name * First Name Last Name Email Address * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Birth Date MM DD YYYY Birth Time Hour Minute Second AM PM Birth Location Please provide at least one emergency contact name, phone number, and email address: * What are you seeking at Succurro? What are you hoping to address, broadly, in your own terms? * Part 2 : Overall Health Describe any current health issues you face (mentally, physically, spiritually, emotionally) Please be as specific as you can be. * List past medical history (injuries, accidents, surgeries, etc) Please describe and include approximate dates. Do you currently take any medications? If so, what are they? Do you currently find any regular or daily activities difficult or limited? If so, please describe. What are your goals in seeking out alternative care? * Please list any other kind of healthcare professional you are seeing, or have seen recently? How much time do you have for yourself to relax, and what activities aid in that relaxation? * How is your sleep? How many hours, on average, do you get and is your sleep restful? If not, please explain. * Would you consider yourself 'addicted' to anything currently? Please describe the relationship. Are you seeking to change this relationship at this time? Take a minute to scan your whole body with your awareness. Please check all the boxes for which you experience pain, tension, discomfort, or blockage. * Head Neck Shoulders Upper Back Middle Back Lower Back Abdominal Muscles Heart Stomach Digestive Track Liver/Gall Bladder Kidneys Spleen Pelvis/Sacrum Arms Wrists Hands/Fingers Buttocks Thighs Knees Shins Ankles Feet/Toes None (congratulations!) Are there any of these you would like to elaborate on? You can include details, level of pain (1-10), etc Rate your level of family stress * None Minimal Moderate High Rate your level of work stress * None Minimal Moderate High Rate your level of relationship stress * None Minimal Moderate High Rate your level of financial stress * None Minimal Moderate High Rate your level of health-related stress * None Minimal Moderate High Please feel free to elaborate on any of the scales above, or add your own area of stress that you'd like to bring forth at this time. Overall, do you experience any of the following feelings to a degree to which you seek help or inquire about? Check all that apply. Abused Criticized Overworked Paralyzed Drepressed Rejected Despair Helpless Hopeless Paranoid Overwhelmed Muddled Persecuted Guilty Easily irritated Anxious Sad Grieving Unable to grieve Apprehensive Agitated Uneasy Distress Fearful Impatient Intimidated Restless Panic Intolerant Uncertainty Aggravated Annoyed Angry Outraged Nervous Worried Please feel free to elaborate on any of the above feelings, or add your own that exemplify your current experience affected Health. Part 3: System Specificity DIGESTION: Which, if any, do you experience, or have experienced in the recent past? Loose stool or diarrhea Constipation Poor digestion Parasites Acid reflux Hernia Nausea/vomiting Gas or belching Stomach or intestinal pain Heartburn Excessive appetite Poor appetite Irritable bowels Hemorrohoids Blood in stool Black or dark stool Light colored stool Difficulty digesting oily foods High cholesterol Gall stones RESPIRATORY: Which, if any, do you experience, or have experienced? Wet cough Dry cough Chest tightness Shortness of breath Congestion Wheezing Nasal problems Poor sense of smell Sinus problems Allergies Hay fever Catching cold easily Pneumonia Asthma Emphysema Bronchitis CARDIOVASCULAR: Which, if any, do you experience or have experienced? Hypertension Hypotension Chest pain Dizziness Easily bruised Edema Cold hands/feet Restlessness Heart palpitations Slow heart rate Poor circulation Blood clots Sweaty hands/feet Anemia Heart disease Phlebitis Heart attack Stroke Poor blood clotting URINARY: Which, if any, do you experience or have experienced? Painful urination Incontinence Difficulty with urination Ringing in ears Ear aches Hearing impairment Kidney stones Kidney infections Low back pain Knee problems NERVOUS: Which, if any, do you experience or have experienced? Dyslexia Learning differences Multiple sclerosis Muscular dystrophy Epilepsy Head injury Numbness Tingling Developmental or growth issues MUSCULAR: Which, if any, do you experience or have experienced? TMJ Pain Facial pain Loss of balance Poor coordination Leg weakness Arm weakness Trunk weakness Difficulty walking Joint swelling Osteoarthritis Rheumatoid Arthritis Artificial joints Broken bones/fractures Pins REPRODUCTIVE Abnormal breast pain or tenderness Breast lumps Nipple discharge Menopausal symptoms Irregular menstrual cycles Painful menses Painful intercourse Ovarian cysts Endometriosis Severe PMS (mood swings, cramping, etc) Infertility Prostate Genital pain Impotence OTHER: Which, if any, do you experience or have experienced? Insomnia Depression Too much sleep Shaky Poor memory Difficulty paying attention Anxiety Easily angered Obsessive tendencies Difficulty making plans or decisions Soft or brittle nails Intolerance to climate changes Fever Chills Nose bleeds Swollen glands Fatigue Difficulty with speech Dry mouth Excessive thirst No thirst Headaches Migraines Dry Eyes Watery Eyes Dental Problems Poor hearing Difficulty wasllowing Weight gain Weight loss Thyroid issues Herpes Candida Shingles Any other additional comments appreciated! Thank you! We will refer to this going forward, and you will also fill one an Exit Form at the end of the program.