Integrix Health, LLC

Comprehensive Chiropractic & Functional Medicine Discovery Session

INTEGRIX HEALTH, LLC

Functional Chiropractic, Medicine & Rehabilitation

22 6th Street North, Moorhead, Minnesota 56560 | Phone: 701-347-1968

Dr. Paul Bekkum, DC, CCEP

"Defeating Dr. Status Quo"

Fax: 701-248-8866 | www.integrix.health

Dual-Specialty Discovery Session Paperwork

Establishing a therapeutic partnership to assess alignment, biomechanics, and systemic root causes utilizing spinal and extremity adjustments, soft tissue therapies, functional rehabilitation, and clinical functional medicine.

Patient Identification

Insurance & Payment Information

Do you intend to utilize health insurance for your physical or chiropractic care?

1. Dual-Specialty Health Story & Goals (ICE Approach)

Part 2: Multi-System Readiness & Mindset Alignment

2. Integrative Readiness for Change

Please rate your current willingness on a scale from `$1$` **(Unwilling)** to `$5$` **(Highly Willing)**:

Q5. How willing are you to significantly modify your diet if we find that certain foods are driving structural inflammation or metabolic symptoms?
1 (Unwilling)
5 (Highly Willing)
Q6. How willing are you to perform daily home physical rehabilitation exercises to support spinal stability and mechanical alignment?
1 (Unwilling)
5 (Highly Willing)
Q7. How willing are you to keep a detailed daily record of your physical symptoms, posture habits, food intake, and stress triggers?
1 (Unwilling)
5 (Highly Willing)
Q8. Are you open to taking targeted biological supplements, modifying work desk ergonomics, and using structural bracing/support as recommended?
1 (Unwilling)
5 (Highly Willing)

3. Confidence & Obstacles

Q9. How confident are you in your ability to dedicate time to consistent physical appointments and intensive lifestyle modifications?
1 (No Confidence)
5 (Extremely Confident)
Q11. How supportive do you think the people in your household will be as you implement physical exercises and metabolic dietary changes?
1 (Very Unsupportive)
5 (Extremely Supportive)

4. Mindset & Model Alignment

Q12. Which statement best represents your healthcare expectations for long-term health?
Q13. Safe and effective structural & metabolic changes require consistent follow-through. How much guided clinical coaching and check-in support do you feel you need?
1 (Self-Guided / Minimal)
5 (Highly Supervised / Close Support)

Discovery Session Commitments

1. Commitment to Dual-Specialty Care Protocols I understand that Functional Chiropractic, Medicine & Rehabilitation is a highly collaborative, active recovery model utilizing spinal and extremity adjustments, soft tissue therapies, functional rehabilitation, and clinical functional medicine. I agree to actively participate in both my physical rehabilitation homework and my metabolic/nutritional guidelines.
2. Diagnostic and Consultation Disclosures I acknowledge that this Discovery Session is an exploratory clinical consultation designed to evaluate treatment compatibility and establish functional biomechanical and metabolic goals. I recognize that it is not an alternative to acute emergency medicine or standard primary hospital care.
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