Ananda Pre-Enrollment Form

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PRE-ENROLLMENT FORM

In order to secure your registration in our Human Performance and Quality of
Life Study or our Chronic Pain Study, please complete the following:
(participation in the study is limited to anyone who has pursued or is currently undergoing one or more of Ananda's wide variety of treatment offerings)

Interested in participating in a study for which you will be compensated?
YES, to learn moreNO, thank you





EmailPhone
Do you have extended health benefits?
YESNO
If YES, then with which insurance provider?
Name of Employer:
Are you covered under a secondary insurance company? (i.e. spousal plan)
YESNO
If YES, then please list name of Secondary Insurance Company:
Select the products or services you have previously tried or are being currently treated with.

Also please indicate whether or not you experienced any success with or are interested in learning more about these treatments.

1

Physical Health Services

Physiotherapy
PastCurrentSuccess: YESSuccess: NOInterested
Osteopathy
PastCurrentSuccess: YESSuccess: NOInterested
Massage Therapy
PastCurrentSuccess: YESSuccess: NOInterested
Acupuncture
PastCurrentSuccess: YESSuccess: NOInterested
Chiropody
PastCurrentSuccess: YESSuccess: NOInterested
Naturopathic Care
PastCurrentSuccess: YESSuccess: NOInterested
Sleep Services
PastCurrentSuccess: YESSuccess: NOInterested
Registered Dietitian or Nutritionist
PastCurrentSuccess: YESSuccess: NOInterested
Chiropractic
PastCurrentSuccess: YESSuccess: NOInterested

2

Non-Physical Health Services

Cannabinoid Therapy
PastCurrentSuccess: YESSuccess: NOInterested
Psychiatry
PastCurrentSuccess: YESSuccess: NOInterested
Psychology/CBT
PastCurrentSuccess: YESSuccess: NOInterested
Neurofeedback
PastCurrentSuccess: YESSuccess: NOInterested
Social Work
Psychotherapy
PastCurrentSuccess: YESSuccess: NOInterested

3

Medical Supplies and Orthopedic Products

IV Vitamin Therapy
PastCurrentSuccess: YESSuccess: NOInterested
Topical Pain Creams
PastCurrentSuccess: YESSuccess: NOInterested
CPAP (Sleep Apnea Devices)
PastCurrentSuccess: YESSuccess: NOInterested
Foot Orthotics
PastCurrentSuccess: YESSuccess: NOInterested
Compression Stocks / Stockings
PastCurrentSuccess: YESSuccess: NOInterested
Back Supports or Braces
PastCurrentSuccess: YESSuccess: NOInterested
Knee Supports or Braces
PastCurrentSuccess: YESSuccess: NOInterested
Ankie Supports or Braces
PastCurrentSuccess: YESSuccess: NOInterested
Wrist / Elbow Supports or Braces
PastCurrentSuccess: YESSuccess: NOInterested
Please provide us with additional information that may be helpful for us or you feel is relative.
If you would like to recommend a friend into the study, please provide us with their contact info:

Name:
Phone:
E-Mail (optional):
Below, please provide us with the name and contact information of the person who referred you to Ananda Clinic:

Referred by:
Phone:
E-Mail (optional):