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Discovery Scope

Understanding the Whole Person, Not Just the Symptoms

Intake Form Part II

By submitting this form, you acknowledge and consent to the collection, storage, and use of your health information for the purposes of providing personalized wellness and clinical services.

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Please review our HIPAA Notice of Privacy Practices

Intake Form Part II

By submitting this form, you acknowledge and consent to the collection, storage, and use of your health information for the purposes of providing personalized wellness and clinical services.

​

Please review our

HIPAA Notice of Privacy Practices

To make the process more manageable, the intake is divided into four separate sections, allowing you to complete the assessment one part at a time. Depending on the complexity of your health history and the level of detail you choose to provide, the total completion time for all four sections may range from approximately 15 to 75 minutes.

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Before You Begin: Each section must be completed and submitted in its entirety before proceeding to the next. For privacy and security purposes, your responses are not automatically saved, and partially completed sections cannot be stored, submitted, or resumed at a later time. We therefore encourage you to set aside sufficient uninterrupted time to complete each part before beginning.

Reminder: The information submitted in Parts I–IV must relate to the same individual. Please use the same Client Identification Code, Date of Birth, and Email Address throughout all four sections. This ensures that each part of your Discovery Scope is accurately matched to your personal health record, even when multiple family members or individuals share the same email address.

Birthday
Month
Day
Year

Women's Wellness

This section pertains to Women's Health. If it does not apply to you, please mark each response as "Not Applicable" (NA)

Do you experience irregular menstrual cycles ? (Pituitary)
Never
Occasionally
Frequently
Almost Always
Not Applicable (NA)
Do you experience heavy or excessive menstrual bleeding ?
Never
Occasionally
Frequently
Almost Always
Not Applicable (NA)
Have you ever experienced ovarian cysts, either currently or in the past ?
Yes
No
Not Applicable (NA)
Do you currently have, or have you previously experienced, uterine fibroids ?
Yes
No
Not Applicable (NA)
Have you ever been diagnosed with endometriosis or atypical cell findings ?
Yes
No
Not Applicable (NA)
Do you experience breast tenderness, fullness, or discomfort, particularly in relation to your menstrual cycle ?
Never
Occasionally
Frequently
Almost Always
Not Applicable (NA)
How would you describe your level of sexual desire (libido) :
Low
Normal
Elevated
Prefer Not to Answer
Not Applicable (NA)
Have you undergone a hysterectomy ?
No
Yes, Partial Hysterectomy
Yes, Complete (total) Hysterectomy
Not Applicable (NA)
If you have undergone a hysterectomy, were any other organs removed ?
Yes
No
Have you ever undergone a D&C (Dilation and Curettage) procedure ?
Yes
No
Not Applicable (NA)
Do you have a history of miscarriage (spontaneous pregnancy loss) ?
Yes
No
Not Applicable (NA)
Have you experienced challenges with conception or fertility ?
Yes
No
Not Applicable (NA)
If yes, was it in the ?
Have you ever taken oral contraceptives (birth control pills) ?
Yes
No
Not Applicable (NA)
Do you have children ?
Yes
No
Not Applicable (NA)
Are you currently planning for or actively pursuing pregnancy ?
Yes
No
Not Applicable (NA)
Are you currently pregnant or believe you may be pregnant ?
Yes
No
Unsure
Not Applicable (NA)
Are you currently nursing or breastfeeding an infant or child ?
Yes
No
Not Applicable (NA)
Details of our Holistic Services ..
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