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Discovery Scope

Understanding the Whole Person, Not Just the Symptoms

Intake Form Part III

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 III

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

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

Lymphatic System

Have you noticed hair thinning, excessive hair shedding, hair loss, or progressive balding ?
No
Mild
Moderate
Significant
Have you ever undergone surgical removal of one or more lymph nodes ?
Yes
No
Not Sure
Have you experienced greying or whitening of the hair ?
No
Mild
Moderate
Significant
Do you experience challenges with memory, focus, or recalling information ?
Never
Occasionally
Frequently
Almost Always
Do you experience recurrent cold- or flu-like symptoms, including fatigue, chills, body aches, or a general feeling of being unwell ?
Never
Occasionally
Frequently
Almost Always
Do you have a history of fibromyalgia, scleroderma, or a related connective tissue disorder ?
Yes
No
Not Sure
Do you experience recurrent sinus congestion, pressure, infections, or other sinus-related symptoms ?
Never
Occasionally
Frequently
Almost Always
Do you experience recurrent sore throats or persistent throat irritation ?
Never
Occasionally
Frequently
Almost Always
Do you experience swollen, tender, or enlarged lymph nodes (glands) ?
Never
Occasionally
Frequently
Almost Always
Have you ever been diagnosed with a tumor, growth, or abnormal mass ?
Yes
No
If yes, what type of abnormal growth, mass, or lesion was diagnosed ?
Fatty
Benign
Malignant
Do you have a history of low platelet counts (thrombocytopenia) ?
Yes
No
Not Sure
Have you ever experienced appendicitis ?
Yes
No
Not Sure
Have you undergone surgical removal of the appendix (appendectomy)?
Yes
No
Do you experience cysts, boils, pimples or other persistent changes in skin appearance ?
Do you engage in regular exercise or physical activity for at least 20 minutes as part of your lifestyle ?
Never or rarely
Occasionally
Several Times per Week
Daily
Have you ever experienced recurrent or significant abscesses ?
Yes
No
Not Sure
(Women only) Have you ever experienced preeclampsia (toxemia) or pregnancy-related high blood pressure ?
Yes
No
Not Sure
Do you have a history of cellulitis (a bacterial infection of the skin and underlying tissues) requiring medical treatment ?
Yes
No
Do you currently have or have you ever experienced or been diagnosed with gout ?
Yes
No
Not Sure
Do you experience blurred vision, visual disturbances, or difficulty focusing your eyesight ?
Never
Occasionally
Frequently
Almost Always
Do you notice mucus, discharge, or crusting around the eyes when you wake in the morning ?
Never
Occasionally
Frequently
Almost Always
Do you snore ?
Never
Mild (Occasional, quiet snoring that rarely disturbs others)
Moderate (Regular snoring that can be heard outside the bedroom or occasionally disturbs others)
Severe (Loud, frequent snoring that regularly disturbs others, may be accompanied by gasping, choking, or pauses in breathing)
Do you have a history of sleep apnea or sleep-disordered breathing ?
Yes
No
Unsure
Have you ever undergone surgical removal of the tonsils (tonsillectomy) ?
Yes
No
Details of our Holistic Services ..
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