Consultation Medical History Intake

Please complete thoroughly. There will be plenty of opportunity to expand on anything not addressed in this history (both at the end of the form and also during our preliminary email exchange in advance of the consultation itself).

Name *
Phone Outside USA
Phone Outside USA
Is the condition getting progressively worse? *
Is this condition interfering with your... *
Has there been a medical diagnosis? *
Have you had a similar problem before? *
Are you on any medications? *
Alcohol intake *
Coffee intake *
Tea Intake *
Tobacco use *
Sugar Intake *
Exercise *
Are you a vegetarian? *
Do you feel you eat a well-balanced diet? *
Are you a shallow breather? *
Have you had any operations/surgeries? *
Have you had any broken bones? *
Have you been in an accident or received a whiplash? *
Please check if you have difficulty with any of the following (there will space at the end of the list to elaborate or clarify): *
Please select from the following consultation options (you will have the opportunity to alter your choice prior receiving an invoice):

What Happens Next?

If you have selected a consultation option and completed the medical history then we will proceed as follows:

1) I will confirm your consultation choice via email. Once confirmed I will send you a PayPal invoice reflecting that choice. You do not need to have a PayPal account. Any credit card will suffice.

2) Once the invoice is paid, I will review the medical history and get back to you within 24 hours by email.

3) If I need more information I may send a few additional questions via email. Sometimes additional information is necessary to insure our consultation is as efficient and focused as possible.

4) Then we will schedule our call.

Thank you for considering a consultation. I will do my utmost to provide you with sound information.*


*Please note disclaimers herein


The information offered during the course of a consultation is provided for educational and informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis or treatment. Never disregard professional medical advice, or delay in seeking it, because of information offered during a consultation. Never rely on such information in place of seeking professional medical advice.

Neuromuscular Therapy of Vermont is not responsible or liable for any advice, course of treatment, diagnosis or any other information, services or products that you obtain through this consultation. You are encouraged to consult with your doctor or other health practitioners with regard to any and all information communicated through a consultation.

 Personal disclaimer

I am not a physician.  I am a Neuromuscular Therapist who specializes in the causes of chronic musculoskeletal pain unrelated to disease processes or pathology. The information I provide is based on my nearly thirty years of experience as a practitioner of manual therapy. Any recommendations I make should be discussed with your doctor to insure there are no mitigating factors I am unaware of.


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