Clinical Somatic Assessment Dena McComb Trauma-Informed Coach, Integrative Health Coach, Yoga Instructor & Brain-Trainer First Name *Last Name *Email Address *I agree to receive emails from Dena McComb**This form only needs to be filled out every 30 days or when there has been changes in your health.What are your goals or intentions in seeking support? *Have you received other types of therapy or coaching for this? (Use N/A if does not apply) *What brings you the most joy, ease, inspiration, or sense of belonging in your life? *List approximate dates and major accidents, surgeries, major injuries, intense relationships, or any difficult experiences you've had in your life. *Do you experience any of the following? (check all that apply)Headache or MigrainesBack PainJaw Pain or ClickingVision IssuesNIghtmaresDigestive IssuesGrind TeethUnexplained Aches and PainsIf you said YES, to any of the above, please explain in space below:Have you experiences any of the following in the last THREE years? (check all that apply)HospitalizationHeart ProblemsStrokeCancerDisc IssuesFibromyalgiaArthritisWhiplashNeuropathySciaticaRepetative Strain InjuryIf you said YES, to any of the above, please explain in space below:What are your feelings around your pain? How does your condition make you feel? *Are you currently undergoing stress or going through an emotionally strenuous period in your life? *YesNoIf you said YES, what are you doing to manage it?On a scale of 1 to 10, how would you rate your current level of stress? (1 being low stress and 10 being the highest) *Have there been any losses or big changes recently in your life? (ie: living situation, work, family or relationships) *YesNoIf you said YES, please share:Is there anything else you would like me to know about you?I do hereby attest that this information is true, accurate and complete to the best of my knowledge.Type your Full Name (First and Last) *Date *SUBMIT
