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Sound Mountain Healing
Patient intake and health survey form

 

The purpose of this form is to provide 3 things for Dr. Kal Sellers DC, MH, as he brings in a new patient and assesses their health needs. Those filling out this form will be contacted and given the opportunity to have Dr. Kal Sellers use it as an intake form to become a patient, to get recommendations and to be able to access the whole site of Sound Mountain Healing.

 

Those 3 things are:
1. Very basic screening calculated to provide warning of deeper, undiagnosed health issues which might warrant going to get diagnosis or at least a checkup from a medical doctor.
2. The overall picture of general health needs and imbalances, likely nutritional deficiencies and dietary shifts needed to rebalance the immune system, nervous system and blood quality.
3. Evidence of specific organ or gland malfunction, using the very simple and reliable language of the body.

The following fields are chosen because these are the specific things Dr. Kal Sellers finds most useful in diagnosing and treating the majority of the patients who enter his practice.

 

This information will enable him to assess your actual HEALING needs. This is NOT a medical diagnosis. For that, please see a medical doctor who is competent in the appropriate specialty.

 

Please fill in the following, then click Submit
You will usually have a response within 48 hours

 

 

Contact Info:

Name:

Date of Birth:

Phone:

Email Address:

Mailing Address:

1. Have you had any noticeable changes in hearing, balance, vision or sensation in the last 3 months or any disturbances of hearing, balance or vision? Yes No

Describe them:

2. Do you have any new pains which wake you up at night out of a dead sleep? (Not the same as waking up and being in pain, this is the pain definitely waking you up) Yes No

Describe them:

3. Have you had any unexplained weight loss? Yes No

Describe it:

4. Have you had any unexplained lumps appear? Yes No

Describe them:

5. In 250 words or less describe your sleeping habits, including time you go to sleep, ease of falling asleep, ease of staying asleep, mood or feelings upon awakening:

6. How many times in the last 3 months have you felt depressed?

7. How many times in the last month have you awakened sweaty?

8. How many times per day does your mood seem to swing?

9. How many times per day do you notice bloat?

10. Do you have ringing in your ears? Yes No

11. Do you want to weigh more or less than you do now? Yes No

Please Explain Why:

12. List your top 3 symptoms:

13. Choose the most important 3 health history issues you think I should know:

14. How many teeth are missing/replaced?

15. What is your favorite exercise?

16. What is your most recent blood pressure (from supermarket is okay):

17. Do you have back pain? Yes No

Where is it?

18. Are you angry about anything that you think about daily? Yes No

How many things?

19. In a crowded room, describe what you do and how you interact (500 words):

20. How often do you have headaches and how severe? (150 words)

21. How often do you get sick? (150 words)

22. Describe the last 3 injuries to your body you can think of (mild or severe), by when they happened, and where the injury was on your body: (500 words)

23. Any other health concerns you feel I should know? (Memory, brain fog, fatigue, joint pain, sensitive to touch, tremors, nightmares, panic attacks, fluid retention, heart palpitations) (500 words)

24. Give any medical diagnoses you have been given: (500 words)

25. Describe what you think of when you think about your health: (500 words)

 

 

 

 

 

 

 

Sound Mountain Healing | info@SoundMountainHealing.com | Phone 307-413-9664
350 South Washington Street , Unit 12
Afton WY 83110