Part 1 : Basic Information
Please provide at least one emergency contact name, phone number, and email address:
What are you seeking at Succurro? What are you hoping to address, broadly, in your own terms?
Describe any current health issues you face (mentally, physically, spiritually, emotionally) Please be as specific as you can be.
List past medical history (injuries, accidents, surgeries, etc) Please describe and include approximate dates.
Do you currently take any medications?
If so, what are they?
Do you currently find any regular or daily activities difficult or limited?
If so, please describe.
What are your goals in seeking out alternative care?
Please list any other kind of healthcare professional you are seeing, or have seen recently?
How much time do you have for yourself to relax, and what activities aid in that relaxation?
How is your sleep? How many hours, on average, do you get and is your sleep restful? If not, please explain.
Would you consider yourself 'addicted' to anything currently? Please describe the relationship. Are you seeking to change this relationship at this time?
Are there any of these you would like to elaborate on? You can include details, level of pain (1-10), etc
Please feel free to elaborate on any of the scales above, or add your own area of stress that you'd like to bring forth at this time.
Please feel free to elaborate on any of the above feelings, or add your own that exemplify your current experience affected Health.
Part 3: System Specificity
Any other additional comments appreciated!
Thank you! We will refer to this going forward, and you will also fill one an Exit Form at the end of the program.