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Consultation Form
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Achieve Vitality Arkansas
Home
Consultation Form
Watch Seminar Online
Consultation Request Form
Url
First Name
*
Date of Birth
*
Last Name
*
Height & Weight
Address
*
Phone Number
*
Email Address
*
Referred By:
Spouse's Name
Spouse Phone Number
Retired?
Yes
No
Occupation
Do you smoke?
Yes
No
If yes, how much?
Do you drink?
Yes
No
If yes, how much?
Do you exercise?
Yes
No
If yes, how much?
What do you consider your current limitation?
*
What do you feel would improve your quality of life?
*
Do you have difficulty (select all that apply)
sleeping
walking
standing
working out
performing self-care activities
working
Do you have difficulty with something other than those listed?
Have you fallen or lost your balance in the last year?
Yes
No
If yes, please explain
If you are experiencing pain check all that describe your symptoms.
aching
stabbing
sharp
throbbing
tingling
hot sensation
swelling
fatigue
heaviness
numbness
dead feeling
coldness
stiffness
reduced mobility
What treatments are you currently using for relief and how well is it working for you? (Medication, Chiropractic, Physical Therapy, Cold/Heat Therapy, Joint Injections, Massage, etc)
Do you have, or have you ever had, any of the following (check all that apply)
Diabetes
High Blood Pressure
High Cholesterol
Vascular Disease
Stroke
Seizure
Anemia
Auto Immune Disease
Chronic Pain
Incontinence
Cancer
Prostate
Arthritis
Heart Disease
Respiratory Issues
Neuropathy
Thyroid
Dementia
Do you have something other than what is listed above?
Are you allergic to any medications?
Yes
No
If yes, please list allergies.
What medications do you currently take? (Please include medication, dosage, and when you take it.)
What supplements do you currently take?
List any surgeries you have had in the past.
Briefly explain your expectations for Infiniti Cell Therapy.
