Intake Form - TLC Educators

Welcome to ROOT: A Centre for Optimal Living

Lifelong health and vitality is our birthright. Few of us know how we lose our health and gaining it back can seem daunting. At Root Centre for Optimal Living we believe that EVERY person has the potential to experience true health, vitality, and an Optimal Life through a vitalistic lifestyle and vitalistic chiropractic care. Our innovative “5 Roots of Health” can help you and your entire family begin the journey of expressing Optimal Health.

This journey will begin with our first Root, restoring Optimal Nerve Flow between your brain and body. By gently removing the interference to your potential with tonal adjustments your body will begin to heal and reorganize from the inside-out and realize a greater expression of life.

Physical, chemical, emotional and mental experiences can accumulate on a daily basis, interfering and challenging your expression of life. This results in aches, pains, and disease, physically, mentally and emotionally.

Knowledge about you will help in understanding who you are, why you are coming to the Centre, what you are expecting and how we may best assist you towards Optimal Living.

Please take a couple of minutes to document your vital Information. If you have any questions, please do not hesitate to ask.

Root Centre for Optimal Living is pleased to serve your family. We are committed to empowering all of you to express your full life potential so you may experience the highest expression of health, well-being & Optimal Living.

First Name

Last Name

Address

City

State

Zip Code

Cell Phone

Work Phone

Occupation

Email *

Date of Birth

Marital Status

Name of Spouse/Partner

Emergency Contact

Emergency Contact Phone Number

Do you have children?

Children Living at Home?

How did you hear about us?

Is there anything about your Nerve System and Spine we should know about?

What is your level of commitment to yourself, your life and journey to Optimal Living?

What brings you to the Centre for Optimal Living today?

What goals are you looking to achieve by becoming a client at Root Centre for Optimal Living?

Everything we have done in the past contributes to who we are today (constructive & destructive). Our goal is to help your body release stored/deep tensions and the more we know about you, the more we can help you with your healing process.

History of Physical Stress, Trauma or Challenges:

The trauma and stress of life is present in all humans (acknowledged or not). Have you had a challenging birth (or delivery), car accident(s), sports injuries, falls, repetitive injuries, etc...?

History of Chemical Stress, Trauma or Challenges:

Chemicals invade our body every second. Our body’s ability to deal with or dispose chemicals is directly related to our expression of Life Force. Are you challenged with asthma, allergies, chemical addictions, toxicity, medication use, previous overdose or poisoning, environmental toxins etc…?

Quality of Nutrition (breakfast, lunch and dinner):

Do you eat junk food, skip meals, diet, etc..? Are you a vegetarian, vegan, raw, macro, meat eater? Do you feel you are lacking something? What are your nutritional goals?

Fluid intake:

What do you drink (water, alcohol, coffee, tea, cow’s milk, diet soda, etc…) and how often?

Exercise:

What type of work do you do or how do you spend your days?

Is it a high or low stress environment and/or experience?

Level of satisfaction with career:

Do you have a positive or negative mindset when it comes to life? Please explain

Any other information about you that you feel may be relevant?

Name