Book Your Discovery Call | Baby Making Bootcamp with Dr. Shaina Nolley

Pathway to Parenthood Intake

Step 1 of 3

You are completing the following intake form for:

The Pathway to Parenthood Discovery Call with Dr. Shaina Nolley

*Dr. Nolley can only see patients who reside in California or Texas*

This is a “quick form” that sets the foundation of our virtual Pathway to Parenthood Discovery Call.

We recommend allotting 5-10 minutes of your time to complete the questionnaire in its entirety. All information is kept completely confidential.

You MUST complete the CONSENT for Email Communication at the end in Section 3 before clicking submit.

We are so excited you are here!

First Name *

Last Name *

Preferred Name (if different)

Email *

Mobile Phone *

Please provide at least one phone number. Your mobile number can be used to look up your Account and receive text message appointment reminders.

Address

Street Address *

City

State

Country

Postal code

Date of birth *

Occupation *

How did you hear about us? *

Our systems and methods are structured to uncover and identify root cause patterns. We use a combination of diet, lifestyle, and supplement recommendations to create a physiological change.

Caim Chiropractic + Functional Medicine operates as a cash-based practice and does not bill health insurance or Medicaid/Medicare. We gladly accept debit, credit, FSA, and HSA cards for your convenience.

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Step 2 of 3

Questionnaires

What inspired you to explore functional approaches to support your fertility journey? *

Have you noticed any issues with your digestion (e.g., bloating, irregular bowel movements) or hormonal symptoms (e.g., irregular cycles, mood swings)?

What are your top priorities or concerns when it comes to preparing for pregnancy?

Have you made any dietary or lifestyle changes recently to support your health and fertility goals?

CANDIDA SCREENING QUESTIONNAIRE

Answering these questions and adding up the scores will help you and your clinician decide if yeast/fungus may be contributing to your health problems.

For each question that is a YES, check the box and then TOTAL your score and record it at the end of the section.

Yeast/Fungal Overgrowth TOTAL (total points from checked boxes above)

Your Total Points

60 points or above: possible yeast/fungal overgrowth

100 points or above: likely yeast/fungal overgrowth

150 points or above: highly likely yeast/fungal overgrowth

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Step 3 of 3

Consents

You can opt to receive emails to keep you informed of new bookings, changes to your bookings, and reminders for upcoming appointments.

I would like email notifications of new, cancelled, and rescheduled appointments

Stay Informed:

We use email to share office closure announcements, free class schedules, and special sales. Yes, I’d like to receive emails from Caim Chiropractic + Functional Medicine.

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Book your Pathway to Parenthood Discovery Call

Pathway to Parenthood Intake