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
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M.I.
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Last Name
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Age
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Birth Date
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Gender
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Ethnicity
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Relationship Status

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Duration of Relationship
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Number of Children
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Children Still residing in the Home
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Student / Employment Status

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

Primary Care Physician (PCP)
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Phone Physician
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Address
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Symptoms / Treatment Symptoms

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

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

Medical Problem
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Active Problem / Health Concern
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Date of Onset
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Surgical Procedures (Last 10 Years)

Surgical Procedure
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Type of Surgery
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Date of Onset
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Allergies

Allergy
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Drug / Food
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Reaction
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Current Medications Prescribed for Pain, Sleep Disturbance, Mental Health Conditions, Etc.

Medication
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Dose
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Started
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Frequency
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Reason
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Doctor
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MEFS Programs and Services

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

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