New Patient Intake Form

Please note that all fields followed by an asterisk must be filled in.
Married
Single
Divorced
Widow
Female
Male
Yes
No
Ever had any head injuries?
Do you have bad dreams?
do you have bleeding gums?
Do you have edema/swelling?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
PMS
Vaginal Pain
Clotting
Discharge
Vaginal Sores
Vaginal Dryness
Other
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Laid-back, easy going and non-confrontational
Firm and strong but non-confrontational
Very strong, confrontational and regimented
Yes
No
Brainstorming strategies together
Support, encouragement and validation
Insight into who you are and your potential
Painting a vision of what you can become or accomplish
Exploring and removing blocks and obstacles to your success
Accountability; checking up on goals
Working through self-improvement programs together
Suggesting or designing action steps
Role play scripts and presentations
Yes
No

Please enter the word that you see below.

  

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