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Intake form

Please let us know more about you and how can we help you

First Name

Last Name

Phone

Why are you seeking out Pain Coaching?

Where is your pain located? List all areas where you feel pain or discomfort:

When did your pain first come on? Did you suffer an injury? Please describe:

Have you received a medical evaluation for your issue? If so, please provide your diagnosis and any relevant MRI findings or test results.

Is your pain localized or does it move locations?

Please indicate if you experience pain frequently or only during certain activities or under certain circumstances. Provide a list of the activities or circumstances that cause you the most pain, such as walking, sitting, running, going to the gym, or changes in weather or time of day, to name a few.

Do you experience any periods of pain relief, such as during vacations, socializing, or while consuming alcohol?

What makes the pain better or worse?

What methods have you tried to relieve your pain? For instance, physical therapy, acupuncture, surgery, stretching, epidurals, yoga, heat/ice, lasers, medication, etc. Please list everything you've tried and what the outcome was.

Do you feel stressed during the day 1-10? What activities during your day cause you stress?

Are you open to the idea that your pain can be treated without drugs, surgery, or any other procedure that treats only the body?

Do you feel you have hit rock bottom with no way out?

Kristen V. Pierce

Let's Connect

Intake form

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