Health Examination Fields marked with an * are required Patient Name Diagnosis Group Name Occupancy Rate: How many patients will be attended to? Single (individual) Group (party) Regimen: How often will you be checking in? just for now, and deciding later sometimes – once per week or less often – multiple times per week daily - once per day all the time - multiple times per day Dosage: How much time do have for treatments? 5-10 min 15-20 min 30(+)min 1 hour 2-3 hours >3Hours Length of treatment: How long with you be committed to your healing? No commitment 1 week 1 month 2-3 months 3-6 months 6-12 months multi-year What is your age(s)? (select as many that apply) under 10yrs. 10-14 yrs. 15-19 yrs. 20-30 yrs. 30-40 yrs. 40-50 yrs. 50-60 yrs. 61+ Insurance: What are your main health objectives and goals for your therapy? Email * Date If you are a human seeing this field, please leave it empty.
