Client Intake Forms Parkinson's New Client Intake form Initial Parkinsons Intake Form Part 1 Section BreakFirst Name(Required)Last Name(Required)Email(Required) Age(Required)Date of Parkinsons Diagnosis(Required) Month Day Year Briefly Describe Your Initial Symptoms(Required)Have Symptoms Changed or Progressed Over Time? If yes, how?(Required)Section: Medical HistoryDo You have any other diagnosis of chronic health condition?(Required)Do You Take Any Medications? If Yes, please list them:(Required)Have you had any surgeries, injuries, or hospitalizations that may be relevant?(Required)Section: Treatment HistoryWhat conventional treatments have you used for Parkinson’s? Medication(Required) Yes No Physical Therapy(Required) Yes No Occupational Therapy(Required) Yes No Speech Therapy(Required) Yes No Deep Brain Stimulation(Required) Yes No Other (please describe below)(Required) Yes No If other, please describe belowWhat complementary or alternative approaches have you tried or are currently using? Acupuncture(Required) Yes No Massage(Required) Yes No Energy Healing or Reiki(Required) Yes No Chiropractic Care(Required) Yes No Yoga / Tai Chi / Qigong(Required) Yes No Nutrition / Supplements(Required) Yes No Other (please describe below)(Required) Yes No If other, please describe belowPlease list the frequency and duration of current therapies (e.g., PT twice a week for 6 months)(Required)Section: Daily Functioning & LifestyleHow would you describe your mobility on a typical day?(Required) Fully independent Some assistance needed Major difficulty or use of mobility aids Do you experience any of the following Tremors Muscle Stiffness Slowness of Movement Balance Issues Freezing Episodes Fatigue Difficulty Sleeping Depression Anxiety Fear Digestive problems Difficulty speaking or swallowing Other (please list below) If other symptoms, please list:Are you currently working or retired Yes No How often do you exercise or move intentionally per week?(Required)What kinds of activities help you feel better physically or emotionally?(Required)Section: Goals & IntentionsWhat are your top 3 goals for working with Brendan Thorson and Vital Energy Medicine?(Required)Is there anything you hope to learn, feel, or change during this process?Section: Symptom Ratings (Scale 1-5)Instruction: "Please rate the following symptoms"Tremors(Required) None Mild Moderate Severe Extreme Muscle Stiffness or rigidity(Required) None Mild Moderate Severe Extreme Slowness of movement(Required) None Mild Moderate Severe Extreme Balance problems(Required) None Mild Moderate Severe Extreme Fatigue(Required) None Mild Moderate Severe Extreme Sleep problems(Required) None Mild Moderate Severe Extreme Depression or emotional lows(Required) None Mild Moderate Severe Extreme Anxiety of excessive worry(Required) None Mild Moderate Severe Extreme Digestive Issues(Required) None Mild Moderate Severe Extreme Memory or mental clarity issues(Required) None Mild Moderate Severe Extreme Cold hands or feet(Required) None Mild Moderate Severe Extreme Pain or discomfort in the body(Required) None Mild Moderate Severe Extreme Restless legs or nerve discomfort(Required) None Mild Moderate Severe Extreme Groundedness / connection to body(Required) Absent or very low Low Moderate High Very high Energy Level Throughout the day(Required) Very low Low Moderate High Very high Voice Strength or clarity(Required) Very low Low Moderate High Very high Poor Posture (hunched, collapsed, sway back)(Required) None Mild Moderate Severe Extreme Confidence and motivation(Required) Very low Low Moderate High Very high Sexual Vitality(Required) Absent or very low Low Moderate High Very high PhoneThis field is for validation purposes and should be left unchanged.
