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Intake Form

Thank you for taking the time to give Megan more detail prior to your paid consultation.

If you don't have time to complete this form in one sitting, please be aware that the form may 'time out' if left idle for an extended period of time. You might consider preparing your answers in advance and then copy/pasting the more lengthy responses in the form fields.

Congratulations on your progress towards healing!

Name(*)

Please tell us your name.

Email(*)

Please include a valid email address.

City

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State/Province

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Country(*)

Please select your Country of residence.

Phone

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Gender(*)

Male

Female

What is your gender?

Age

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How long have you suffered symptoms?

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How do you think you got this?

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Describe First Symptoms (incl. parts of body)

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Anyone else near you affected

Yes

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Do they live with you

Yes

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What is their age and sex and how long have they had symptoms?

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Have you seen any doctors and if so what kind?

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What did they tell you? What did they prescribe?

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Describe what you have tried on your own to rid yourself of this?

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Have you taken anything internally and did you see any results?

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How was your general health before you got this?

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What is your health like now?

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What other health issues did you have and what kinds of medication were you taking?

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Are you

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Do you:

Smoke

Drink

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Do you drink coffee or sodas? How many a day?

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Do you eat junk food? How often?

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What is your diet like? Describe an average day and times you eat.

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What sort of work do you do?

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Do you exercise and if so how often?

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What do you do for exercise?

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How much time do you spend outdoors?

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Do you have any pets and are they affected? Describe how.

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Besides your own pets do you have animals around your house?

Yes

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Have you tried pest control companies?

Yes

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What did they do and what did they charge you?

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How large is your home?

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Is your home crowded? With what?

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Do you have any symptoms that have been unchanged since the beginning?

Yes

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If yes, what and where on your body are they?

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Are you sleep deprived?

Yes

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Is your bed a problem area?

Yes

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What kind of mattress do you have? How old is it?

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Does your pillow bother you?

Yes

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What kind of pillow and how old?

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Do you have any symptoms on your head or face? Please describe.

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Do you have this in you ears or nose?

Yes

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Are any areas of your skin numb?

Yes

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Does eating affect the symptoms? How and what foods?

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Does sweating affect the symptoms?

Yes

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Did your first symptoms change to any other areas? Did they expand or go away and appear on a different part of the body?

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When did it change and to what areas?

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Do you currently have any activity:

On your feet or ankles

In the folds of any skin

Your arms, back, chest etc

On the larger surfaces of your body

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Please Describe

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Are you able to work?

Yes

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Is there anything else you want me to know?

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