Parkinson’s Healing Intake Form

Start your journey with Brendan Thorson – Vital Energy Medicine

Living with Parkinson’s can affect every part of your day—and I want to help you reclaim strength, stability, and a deeper sense of well-being. This form is your first step toward working with me through Vital Energy Medicine, a unique approach to restoring your body’s energy, vitality, and internal balance. Please complete this intake form before your first session so I can understand your specific symptoms, goals, and where you most want support.

If you have any questions, I’m here to help.

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.

First Name(Required)

Last Name(Required)

Email(Required)

Enter Email Confirm Email

How many years ago were you diagnosed with Parkinson’s disease?(Required)

Your age range?(Required)

(Less than 50)

(50 -- 59)

(60 -- 69)

(70 -- 79)

(80 and above)

Briefly Describe Your Initial Symptoms(Required)

Have Symptoms Changed or Progressed Over Time? If yes, how?(Required)

Section: Medical History

Do you have any other chronic health challenges you’d like to mention?

If you wish, please list any medications you feel are relevant?

Have you had any surgeries, injuries, or hospitalizations that may be relevant?(Required)

Section: Treatment History

What conventional treatments have you used for Parkinson’s?

Medication(Required)

Yes

Physical Therapy(Required)

Yes

Occupational Therapy(Required)

Yes

Speech Therapy(Required)

Yes

Deep Brain Stimulation(Required)

Yes

Other (please describe below)(Required)

Yes

If other, please describe below

What complementary or alternative approaches have you tried or are currently using?

Acupuncture(Required)

Yes

Massage(Required)

Yes

Energy Healing or Reiki(Required)

Yes

Chiropractic Care(Required)

Yes

Yoga / Tai Chi / Qigong(Required)

Yes

Nutrition / Supplements(Required)

Yes

Other (please describe below)(Required)

Yes

If other, please describe below

Please list the frequency and duration of current therapies (e.g., PT twice a week for 6 months)(Required)

Section: Daily Functioning & Lifestyle

How 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:

What is your biggest health challenge right now?(Required)

What is your current work status?

Working full-time or part-time

Retired

Not working at this time

Other

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 & Intentions

What 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

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)

I agree that my self-reported progress data may be used anonymously (without my name or contact information) for educational, promotional, or early research purposes to help others understand the potential benefits of this work.

Comments

This field is for validation purposes and should be left unchanged.

Thank you for taking this important step. I look forward to supporting your progress every session. Book your first healing session today or learn more about how Vital Energy Medicine helps people with Parkinson’s feel stronger, steadier, and more hopeful.

Brendan Thorson
Vital Energy Medicine