Please enable JavaScript in your browser to complete this form.123456789101112The BasicsNameFirstLastLayoutEmailPhoneLayoutDate of BirthGenderMaleFemaleTransgender MaleTransgender FemaleUnspecifiedLayoutEmergency ContactEmergency Contact PhoneLayout (copy)OccupationWho may we thank for referring you to WeHeal? (optional)To help give some personality to otherwise faceless data, we hope you'll upload a photo of yourself! Click or drag a file to this area to upload. What would you like to accomplish in your work with WeHeal? Visual Text NextHealth History and Statusheight & weightHeight (feet)Height (inches)WeightGoal weight (if applicable)Do you have any current diagnoses you'd like us to be aware of?YesNoPlease elaborateDo you have any past diagnoses you'd like us to be aware of?YesNoPlease list any past diagnoses you'd like us to be aware of.Diagnosis 1Diagnosis 2Diagnosis 3Diagnosis 4LayoutAre you currently pregnant?YesNoAre you currently breastfeeding?YesNoLayoutDo you have any known drug allergies?YesNoAllergy 1Allergy 2Do you regularly take any over-the-counter medications?YesNoPlease indicate any over the counter medications you are regularly taking (or their generic equivalent):TylenolAdvilBenadryl (antihistamine)Tums/Rolaids/Mylanta (antacids)Pepcid/Tagamet (H2 blockers)Prilosec/Prevacid (protein pump inhibitors)Robitussin or other cough suppressantssNoneOther (please list below)Name of medication, if otherRecreational SubstancesLayoutAre you a smoker?YesNoHow many per day?For how many years?LayoutDo you drink alcoholic beverages?YesNoHow would you describe your alcohol consumption?I drink once a week or less.I drink socially 2-3 times per week.I routinely drink wine, beer, or mixed drinks with dinner.Do you use any recreational drugs, such as marijuana?YesNoHow would you describe your recreational drug use?I never use any recreational drugs.I use recreational drugs once in a while.I often use recreational drugs.PreviousNextSleep and EnergyLayoutWhat time do you typically go to sleep?What time do you typically wake up?How many times do you wake up or get up to go to the bathroom at night on average?None1-2 times3 or more timesLayoutDo you consume caffeine in any form?YesNoi.e. coffee, chocolate, tea, energy drinks, pills, etc.What type of caffeinated drinks do you enjoy?CoffeeGreen or black teaYerba MateEnergy drinksOtherIf other, please describe:LayoutDo you ever use sleeping pills?YesNoName of medicationDoxepin (Silenor)Doxepin (Silenor)EstazolamEszopiclone (Lunesta)Ramelteon (Rozerem)Temazepam (Restoril)Triazolam (Halcion)Zaleplon (Sonata)Zolpidem (Ambien, Edluar, Intermezzo, Zolpimist)Zolpidem extended release (Ambien CR)Suvorexant (Belsomra)OtherMay we ask a few more questions about your sleep habits?Sure thing.No thanks.LayoutI wish my energy level was better in the morning. Selected Value: 5 1 = strongly disagree | 10 = strongly agreeI feel rested and restored when I wake up in the morning. Selected Value: 5 1 = strongly disagree | 10 = strongly agreeI function optimally throughout my day without a nap. Selected Value: 5 1 = strongly disagree | 10 = strongly agreeI wish my energy level was better in the evening. Selected Value: 5 1 = strongly disagree | 10 = strongly agreeI function optimally throughout my day without caffeine. Selected Value: 5 1 = strongly disagree | 10 = strongly agreePreviousNextNutritionHow much of the following do you consume on average per day?LayoutVegetablesWhole Grainsbrown rice, quinoa, corn, etc.Legumesbeans, lentils, etc.Vegetarian imitation meats or protein powdersBeyond Burger™, isolated proteins, etc.FruitsStarchy Vegetablespotatoes, squash, etc.Refined Grainswhite rice, white bread, etc.Added sweeteners and sugars (tablespoons)sugar, syrup, honey, etc.Can we go a little deeper about your dietary habits?Nutrition is a big deal to me, and I'd like to answer a few more questions. Not now, thanks.LayoutI am very happy with my diet Selected Value: 5 I have no difficulty following the diet I follow Selected Value: 5 I know very little about nutrition and have no idea what a healthy diet is Selected Value: 5 When I imagine trying to eat the way I eat today for the rest of my life, I feel really depressed and deprived Selected Value: 5 If I knew what healthy foods were then I would eat them Selected Value: 5 I believe my diet is health promoting Selected Value: 5 It wouldn’t hurt me to eat a little better Selected Value: 5 I know what to eat but have a hard time choosing those foods Selected Value: 5 If healthy food tasted better I would eat that Selected Value: 5 If I knew how to cook healthy foods then I would eat them Selected Value: 5 PreviousNextActivityOn average, how many days per week are you engaged in exercise of some kind?I exercise 1-2 days each week.I exercise 3-4 days each week.I exercise nearly everydayI rarely engage in any deliberate physical activityWhat types of exercise do you typically do?PlayWhat do you do for fun? Be as detailed as you like.Play is any actvity you enjoy that isn't intended to achieve a goal or a predetermined outcome. These can be physical activities, social activities, hobbies, games, etc.What activities do you engage in to "numb out” or “check out” from reality during a week on averageNetflix, social media, etc. PreviousNextSelfHow much of your true self do you keep private? Approximate using a percentage. Selected Value: 5 % On a scale from 1-10 how much do you agree with the following statement: I wish my life were different Selected Value: 5 (1 = that doesn't sound like me at all; 2 = that describes me to a tee)Would you be willing to answer a few more related questions?YesNoThe more information you can provide now, the more prepared we'll be to address your issues in our appointment.We appreciate your honesty. Would you mind answering a few related questions, so we're best prepared when we meet?YesNoLayoutThere are things that I wish I did differently Selected Value: 5 I feel stressed out more often than I would like Selected Value: 5 I feel depressed more often than I would like Selected Value: 5 I don’t like to feel embarrassed and try to avoid that from happening Selected Value: 5 I allow myself to feel sad and trust it will pass Selected Value: 5 I try not to feel afraid or embrace feeling nervous or worried Selected Value: 5 In general I feel openhearted/touched Selected Value: 5 In general I feel expansive/open In general I feel peaceful/serene Selected Value: 5 I get angry more than I would like Selected Value: 5 I feel anxiety more often than I would like Selected Value: 5 I feel guilt more often than I would like Selected Value: 5 I feel ashamed, embarrassed or judge myself harshly more often than I would like Selected Value: 5 I wish I had more close relationships Selected Value: 5 In general I feel enthusiastic and invigorated Selected Value: 5 In general I feel happy/cheerful Selected Value: 5 How many times a week, if at all, do you meditate?Interpersonal CommunicationLayoutI wouldn’t change anything about how I communicate and relate with my spouse/partner, or how they communicate and relate to me. Selected Value: 5 1 means "I am very unhappy with our communication" & 10 means "I am very happy with our communication"I wouldn’t change anything about how I communicate and relate with my friends, or how they communicate and relate to me. Selected Value: 5 1 means "I am very unhappy with our communication" & 10 means "I am very happy with our communication"To give us more insight, may we ask a few more questions about your connection with others?YesNoLayoutI am comfortable sharing what I feel inside and don’t feel the need to keep most things private Selected Value: 5 Other people really enjoy the way I talk and communicate with them Selected Value: 5 I tend to feel nervous sharing some things that are important to me with other people because I worry about their reaction Selected Value: 5 I wouldn’t change anything about how I communicate and relate with my extended family Selected Value: 5 I always feel heard by my spouse/partner Selected Value: 5 I always feel heard by my extended family members Selected Value: 5 I am really happy with how I talk and communicate with others Selected Value: 5 Other people would describe my communication and interactions with them as warm and compassionate Selected Value: 5 I wouldn’t change anything about how I communicate and relate with my children Selected Value: 5 I am always authentic and honest and don’t hide any feelings or needs out of fear of other people’s reactions Selected Value: 5 I always feel heard by my children Selected Value: 5 I always feel heard by my friends Selected Value: 5 PreviousNextWorkWhich statement best describes your relationship with your work?I feel depleted by my workI feel invigorated and energized by my workMy current job is fulfilling my need for meaning and purpose Selected Value: 6 1 means "I am entirely unfulfilled in my current job" • 10 means "I am completely fulfilled in my current job."If I won the lottery today, I wouldn’t change anything about my current work activities and would continue doing the same work tomorrow Selected Value: 5 1 means "I'd woudn't even bother packing up my desk" • 10 means "I'd be there the next morning like nothing happened."It sounds like this is an area we'll want to look at together. May we ask a few more questions to better prepare us?YesNot nowLayoutAll of the people I interact with at work on a daily basis are enjoyable and I would call them my friends Selected Value: 5 At work, I always communicate with compassion, authenticity, and honesty Selected Value: 5 At work, I trust that my team cares about me Selected Value: 5 At work, I am required to keep my personal life separate and not allow my personal life to affect my work life Selected Value: 5 At work I do everything because I choose to not because I have to Selected Value: 5 At work, I always feel heard and understood - even if people don’t agree with my ideas Selected Value: 5 At work, I trust that my boss cares about me Selected Value: 5 SpiritualityFor these next few questions, fill in the blank with whatever first comes to mind:LayoutWhat gives me hope is:What gives me comfort is:What gives me strength is:What gives me peace is:Did you enjoy answering those questions?Yes, they helped me understand a little more abut myself.I'm not really comfortable with those kinds of questions.Since those questions resonated with you, here are a few more that may stimulate some more personal discovery.We understand. Let's move on to something else!LayoutI actively contribute to a greater purpose than myself Selected Value: 5 I am someone who has faith and trust that life will work out for people Selected Value: 5 I feel connected to a higher power (whatever that means to me) Selected Value: 5 What aspects of your spirituality or spiritual practices do you find most helpful?PreviousNextThe Natural WorldHow often do you spend time in nature or outdoors?hours per weekThat's actually more time than most people.We'd like to understand more about your relationship with the natural world. Indicate your resonance with the following statements, where 1 = strongly disagree and 10 = strongly agreeWow, that's great - tell us more!Indicate your resonance with the following statements, where 1 = strongly disagree and 10 = strongly agreeLayoutI value the natural world, from caring for the environment to caring for all living creatures. Selected Value: 5 I live in a way that is compassionate to all animals. Selected Value: 5 I would like to do more to support the environment but am not sure what to do. Selected Value: 5 I live in integrity with the value I place on the natural world, and my actions clearly support my care for the planet. Selected Value: 5 I live in a way that cares for and protects the environment. Selected Value: 5 I would like to do more to support the environment but just don’t have the time or bandwidth to do so. Selected Value: 5 PreviousNextYou're doing great!Let's take a moment to acknowledge the time and thoughtfulness you've given yourself. With the information you've shared so far, we'll be able to jump right in when we finally meet.These last few questions will give us insight and help us be better prepared for our work together.NextHave you experienced any of these symptoms in the last 12 months?Anxiety symptoms and/or panic attacksBack painBell’s palsy, facial paralysisBinge EatingCarpal tunnel syndromeChest painChronic tendonitisColitis, spastic colonConstipationDepressionDiarrheaDizzinessEating disordersEczemaFatigue or Chronic fatigue syndromeFibromyalgiaHeartburn, acid refluxHiatal herniaHyperventilationInsomnia or trouble sleepingInterstitial cystitisIrritable bowel syndromeMigraine headacheMuscle tendernessNeck painNumbness, paresthesiasObsessive-compulsive thought patternsPalpitationsPelvic painProstate problemsReflex sympathetic dystrophy (RSD)Repetitive stress injuryShoulder painSpastic bladderTachycardia or low blood pressureTemporo-mandibular joint syndrome (TMJ)Tension headacheTinnitusTrigeminal neuralgia, facial painUlcer symptoms or stomach painsNoneHistory of stressors related to the symptoms you indicated above:Illness or death in your family or friendsDivorce or marital problemsLegal problemsAccident or injuryNew relationship or marriageDifficulties at work or change in job or businessGain of a new family member or change in the familyChange in financial situationChange in living situationViolent experiencesChanges in sexual functioning or other issues regarding sexNoneHave you had any of the following experiences in childhood?Long-term emotional abuse, such as insults or humiliation.Long-term physical abuse like being pushed, grabbed, slapped, or being hit hard that you had marks?Sexual abuseFeeling not loved, not special, or not important to your family, or that your family was not supportive of each other or close to each other?Feeling often that you were neglected (didn’t have enough food, clean clothes, or parents were too intoxicated to take care of you)Your parents ever separated or divorcedYour mother or stepmother was often abused emotionally or physicallyYou lived with someone with addiction to alcohol or drugsYou lived with someone who was depressed or mentally ill, or attempted suicide?Someone in your household went to prison.I don't recall any traumatic experiences in my childhood.Please indicate if you would you describe yourself as having any of these personality traits:Having low self-esteemBeing a perfectionistHaving high expectations of yourselfWanting to be good and/or be likedFrequently hostile and/or aggressiveFrequently feeling guiltFeeling dependent on othersBeing conscientiousBeing hard on yourselfBeing overly responsibleOften responsible for othersHaving rage or resentmentOften worryingBeing sadHave difficulty making decisionsA rule-followerHave difficulty letting goCautious, shy, or reservedTend to hold thoughts and feelings inNone of these describes my personalityNextCore RelationshipsLast but certainly not least, list the first names of the most important relationships (family, friend, or colleague) in your life:Connection 1First name only is OKRelation to you:SpouseChildSiblingExtended familyProfessional colleagueFriend outside workHow deeply connected you feel in that relationship right now?Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10Connection 2First name only is OKRelation to you:SpouseChildSiblingExtended familyProfessional colleagueFriend outside workHow deeply connected you feel in that relationship right now?Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10Connection 3First name only is OKRelation to you:SpouseChildSiblingExtended familyProfessional colleagueFriend outside workHow deeply connected you feel in that relationship right now?Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10Connection 4First name only is OKRelation to you:SpouseChildSiblingExtended familyProfessional colleagueFriend outside workHow deeply connected you feel in that relationship right now?Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10Connection 5First name only is OKRelation to you:SpouseChildSiblingExtended familyProfessional colleagueFriend outside workHow deeply connected you feel in that relationship right now?Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10PreviousNextUse this space to share anything else you'd like us to know.AcknowledgementTo the best of my knowledge, the information provided above is true and accurate. I agree to tell WeHeal, Inc. any changes to my health history or medications as they arise. I understand that information is necessary for WeHeal, Inc. and will remain confidential. All efforts are routinely made to ensure privacy is upheld.Section DividerSubmit and go to consent forms
