General Chronic Illness Intake Form

Chronic Illness & General Health Intake Form

Welcome. I’m glad you’re here.
This form is the first step in helping me understand your unique health challenges, goals, and the deeper energetic patterns behind them. Whether you’re facing a long-term chronic illness or simply feeling run down and ready for change, your answers will help me tailor our work together so you can start restoring your energy, rebuilding strength, and moving toward real healing. Everything you share is private and used only to guide your healing journey. If you have any questions, feel free to reach out before or after you complete the form.

Purpose & Use

Your answers help me customize your sessions and track how your energy and symptoms change over time. I use your self-reported progress to guide our work together and to better understand how this healing method can support others with similar challenges. This form is not a medical intake and does not replace diagnosis or treatment. Please answer honestly—your responses are a key part of your healing process and my ongoing learning.

Section 1 -- Basic Information

Name(Required)
Email(Required)
Age range(Required)

Section 2 -- Health Background

SECTION 3 — Symptom Overview (Physical)

• Fatigue or low energy(Required)
• Muscle or joint discomfort(Required)
• Sleep issues(Required)
• Digestion or stomach discomfort(Required)
• Cold hands, feet, or circulation issues(Required)
• Hormone or mood fluctuations(Required)
• Getting sick easily (low immunity)(Required)
• Low sexual or reproductive energy(Required)

SECTION 4 — Mental & Emotional Well-Being

• Feeling anxious or tense(Required)
• Feeling down or discouraged(Required)
• Excessive worrying or overthinking(Required)
• Difficulty feeling calm or centered(Required)
• Difficulty staying positive or hopeful(Required)
• Difficulty expressing emotions(Required)

SECTION 5 — Goals & Commitment

• How motivated are you to actively participate in your healing journey?(Required)
Privacy & Sharing
Your answers are used to personalize your sessions, track your progress, and help Vital Energy Medicine understand and share general trends in a way that educates, inspires, and informs others, including potential research partners. We will never share your name or contact information without your explicit written consent.
Consent(Required)
This field is for validation purposes and should be left unchanged.

Thank you for completing this form. Understanding your health challenges and goals helps me personalize your sessions and support you more deeply.

You can now visit the Healing Packages to find the right starting point for your health and recovery goals.

— Brendan Thorson
Vital Energy Medicine