No Charge Consult

You are completing the following intake forms: CURRENT SYMPTOMS QUESTIONNAIRE (CSQ).

Please take a moment to fill out our online Current Symptoms Questionnaire form on the day before or day of your visit and TOTAL your score. All information is kept completely confidential.

First Name

Last Name

Email *

Date of birth

I agree to terms & conditions provided. By providing my phone number, I agree to receive text messages from Health In Motion Wellness.

What are your concerns that had you schedule this 15 minute consult?

Has anything helped you to feel better?

Has anything made you feel worse?

Briefly describe any key information that you would like us to know for your call:

To stay focused and make the most of our short call, please check the items that interest you the most:

If there was ONE question about your health that you would really like answered what would that be?

How well have things been going for you?

On a Scale from 0 to 10, 1 means "poorly", 5 means "fine" and 10 means "very well".

Overall:

PoorlyVery Well

At School:

PoorlyVery Well

In Your Job:

PoorlyVery Well

In Your Social Life:

PoorlyVery Well

With Close Friends:

PoorlyVery Well

With Sex:

PoorlyVery Well

With Dating:

PoorlyVery Well

With Your Children:

PoorlyVery Well

With Your Parents:

PoorlyVery Well

With Your Spouse/Partner:

PoorlyVery Well