Discovery Session Application Please enable JavaScript in your browser to complete this form.First Name *Last Name *Phone *Email *Location (city/state/country) *How did you hear about us? *What is your primary health concern? *Please select any/all that are a current problem for you... *Muscle, Joint and/or Spine PainInstability, Hypermobility and/or hEDSHeadaches and/or MigrainesPosture ConcernsDizziness, POTS and/or Orthostatic SymptomsBrain Fog, Mood and/or Focus ChallengesSleep DifficultiesIrritability, Overwhelm and/or Emotional ReactivityBreathing DifficultiesDigestive IssuesFood Sensitivities and/or Eating ChallengesWeight and/or Blood Sugar ChallengesHormone Imbalances (changes in mood, libido, cycle, etc.)Allergies, Skin and/or Histamine SymptomsFrequent IllnessOtherOn a scale of 0 to 10 (10=highest), how much stress do you feel on a daily basis? Selected Value: 0 Check all options you are interested in learning more about...Quantum Neuro Reset Therapy (QNRT)Postural Restoration (PRI)Jigsaw Journey ProgramFunctional Health & Lab TestingHolistic Occupational Therapy (OT)Holistic Physical Therapy (PT)Health Puzzle Mapping SessionPersonal TrainingHealth CoachingWhat (or who) may prevent you from completing a health unpuzzling program? *SelfSpouse/PartnerChildrenTimeMoneyFearJobResourcesOtherNone of the aboveWhat have you tried so far that has or has not worked? *Do you follow any specific eating approach or have any dietary restrictions? (examples: gluten-free, dairy-free, vegan/vegetarian, low-histamine, macros, WW, intermittent fasting, etc.)Do you have any regular movement or physical activity in your week? If so, please describe below...If we were to work together, what would be your expectations? *On a scale of 1 to 10 (10=hell yes!), how committed to your goals are you? Selected Value: 0 Is there anything else you would like to share?I acknowledge that Health Unpuzzled is a self-pay practice and does not bill insurance for services or programs. *I understand and agree.Payments made via HSA/FSA plans may be an option depending on your situation and service.Submit Address 5754 Blackshire PathInver Grove Heights, MN 55076 Phone (612) 289-6000 Email heal@healthunpuzzled.com
