PJA Wellness

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Personal Information

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Email Address *

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Health Information

Chief Complaint (What brings you here today?) *

How long have you been experiencing these symptoms? *

Current Symptoms (Check all that apply)

Fatigue

Pain

Anxiety

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Sleep Issues

Digestive Issues

Headaches

Stress

Current Medications

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Consent & Agreements

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I consent to receive healthcare services via telehealth and understand the benefits and limitations described above. *

📹 Session Recording Policy

Your telehealth session may be recorded for quality assurance, training, and medical record purposes. Recordings are stored securely and treated as part of your medical record.

I consent to the recording of my telehealth session.

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PJA Wellness

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How We Use Your Health Information

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