Patient Intake Form

Please answer all questions that have an *...if you have questions, please see the bottom of the form for help answering these questions.

Help with above * asterisk* questions

*List activities you did when you were younger:
Take some time and think about it, look at old photos or think about family vacations, siblings and neighbors/friends, and list as many sports, crafts, games, clubs and puzzles…… you can think of as a child or young adult

*LIst activities you did or do as an adult:
Think about how you spent your time when not working or tending to family/ household tasks: play cards, use computer, hike, bike, play tennis, friend gatherings/ BBQs, hobbies: woodworking, knitting, painting, sculpting, fishing, gardening, going to the beach or lake, summer or winter activities……