MEFS Intake Form

Welcome,

We look forward to helping you Unlock your Edge! Please take a moment and complete the MEFS Intake Form to assist us with customizing your program. The more information provided, the better we can assist you with reaching your mental fitness goals.
Please click the next button below or the number 2 above and start the Intake Form.
Average time needed to complete: 2 to 5 min.

Personal Information

Your First Name
M.I.
Last Name
Age
Birth Date
Gender
Ethnicity

Relationship Status

Duration of Relationship
Number of Children
Children Still residing in the Home

Student / Employment Status

Length of Employment
Retire / Unemployment Date
Employer Name and Position
School and grade or Major / Degree

Physician Information

Primary Care Physician (PCP)
Phone Physician
Address

Symptoms / Treatment Symptoms

Do you have any diagnosed medical or mental health conditions?
Please explain
Are you being treated by a medical professional for the above conditions?
By who?
When?
Duration of treatment
Are you currently experiencing any physical pain or discomfort?
Please explain
Are you being treated by a professional for the physical pain or discomfort?
By who?
When?
Duration of treatment
Are there any health-related conditions, concerns or questions that you wish to discuss?
Please explain

Injury Specific Information

(if applicable)
Are your injuries related to an accident?
Please describe

Medical Problems

Medical Problem
Active Problem / Health Concern
Date of Onset

Surgical Procedures (Last 10 Years)

Surgical Procedure
Type of Surgery
Date of Onset

Allergies

Allergy
Drug / Food
Reaction

Current Medications Prescribed for Pain, Sleep Disturbance, Mental Health Conditions, Etc.

Medication
Dose
Started
Frequency
Reason
Doctor

MEFS Programs and Services

What are your intentions and expectations from the Mental Edge Fitness Solutions programs and services?
What other mind-body services have you received currently or in the past?
If "other(s), please specify

Contact Information

Mailing Address
Apt. / Unit #
Allow Mail?
Physical Address (if different)
Apt. / Unit #
Home Phone
Allow messages?
Work Phone
Allow messages?
Cellphone
Allow messages?
Your Email Address
Allow Emails?
Name other contact person in case of emergency
Telephone
Relationship
Signature
Date

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