Survey | Full Circle Health Network

Are you ready to find your best version of you? Our customized wellness plans are exactly that - 100% customized to you! All information that you include in the upcoming questionnaire is 100% confidential. We will NEVER share this information without your expressed written consent.

Are you filling this form in for*
- you
- a loved one?
Their Name*
First Last
Age*

What is the number one health condition you most want to change?*
- Physical Pain (back, joints, neck etc) / Numbness/Tingling/Loss of Sensation
- Sleep Disturbance
- Digestive Problems
- Hormone or Reproductive Organ Issues
- Immune/Autoimmune Conditions
- Concussions/Head Injury
- Mental Wellness
- Cardiovascular Issues
- Neurological Condition
- Pre/Post Natal Care
Check all that apply*
- Back Pain
- Neck Pain
- Shoulder Pain
- Elbow/Hand/Wrist Pain
- Hip Pain
- Knee/Ankle/Foot Pain
- Face/Head/Jaw Pain (including headaches/migraines)
- Fibromyalgia
- Chronic Fatigue Syndrome
- Other
Check all that apply*
- Insomnia
- Sleep Apnea
- Narcolepsy
- Restless Leg
- Sleep Walking
- Other
Check all that apply*
- IBS
- Crohn’s / Colitis
- Reflux / Heartburn/ GERD
- Constipation
- Diarrhea
- Hemorrhoids
- Other
Check all that apply*
- Hypothyroid (low thyroid)
- Hyperthyroid (high thyroid)
- Irregular Menstrual Cycle
- Polycystic Ovarian Syndrome
- Endometriosis
- Fertility (male or female)
- Erectile Dysfunction
- Menopause
- Other
Check all that apply*
- Lyme’s Disease
- Cancer
- Multiple Sclerosis
- Lupus
- Rheumatoid Arthritis
- Diabetes
- Other
Check all that apply*
- Cognitive Fatigue
- Headaches
- Migraines
- Muscle Tension (neck/shoulder)
- Post Concussion Syndrome
- Whip-lash
- Difficulty Performing Day-to-Day Tasks
- Other
Check all that apply*
- Anxiety
- Depression
- Stress
- Grief and Loss
- Relationship Conflicts
- Low Self-esteem
- Post Traumatic Stress Disorder
- Other
Check all that apply*
- Circulatory problems
- Depression
- High Blood Pressure
- Low Blood Pressure
- Heart Attack
- Atherosclerosis
- Stroke
- Arrhythmia
- Blood Condition/Disease
- Congestive Heart Disease
- Other
Check all that apply*
- Alzheimer's
- Dementia
- Parkinsons Disease
- ALS (amyotrophic lateral sclerosis)
- Multiple Sclerosis
- Neuropathy
- Migraines
- Other
Check all that apply*
- Nausea
- Breech/Posterior Babies
- Induction
- Milk Supply/Production
- Lactation
- Wound Healing/Scar Tissue Repair
- Post Partum Depression
- Other
Please Specify*
How long have you been dealing with this condition?*
- Acute onset in past 7 days
- Sub acute 7-28 days
- 1-3 months
- 3-6 months
- 1 year
- 2-5 years
- 5-10 years
- More than 10 years
Please tell us more about your symptoms

Have you sought help for your initial complaint before?*
- Yes
- No

When creating a plan for you that will actually work we need to understand how much time you can devote to resolving this. Our goal is to get you the best results in the fewest number of treatments to ensure your issue is resolved and stays resolved.
I can commit to:*
- More than 1 appointment per week
- 1 appointment per week
- 1 appointment every other week
- 1 appointment per month
- 1 appointment every 3-6 months
- I can commit to whatever it takes to see results

Anything else you’d like us to know or share with us?
Name*
First Last
Phone*
Email*
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