First & Last Name *

First Name

Last Name

Phone *

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Check All That Apply :

I experience problems falling asleep or staying asleep.

I frequently experience a second wind (high energy) after dinner or late at night.

I have energy highs & lows throughout the day and have crashes after lunch.

I feel tired most of the time.

I feel like I need caffeine (cola, tea, coffee, sugar) to get going in the morning & sustain energy.

I usually go to bed after 10 PM.

I wake up between 2-4 AM in the morning.

I frequently get fewer than 8 hours of sleep per night.

I am easily fatigued.

Things I used to enjoy seem like a chore lately.

My sex drive is lower than it used to be.

I suffer from depression, or have been recently experiencing feelings of depression such as sadness and loss of motivation.

I suffer from feelings of anxiousness or anxiety.

My ability to handle stress has decreased.

I find that I am easily irritated or upset.

I have had one or more stressful major life events (divorce, death of a loved one, job loss, new baby, new job) .

I tend to overwork with little time for play or relaxation for extended periods of time.

I crave sweets.

I frequently skip meals or eat sporadically.

I am experiencing increased physical complaints such as muscle aches, headaches, or more frequent illness.

How often are your symptoms affecting you?

check all that apply.

None, just preventative medicine.

A little ( 1-2x a month).

Weekly.

Multiple times a week.

Daily.

Are you willing to travel for in person visits? *

Emily is a licensed nurse practitioner in TN and has certain requirements for treating her patients in TN. However, select one below and she will discuss the options to be able to work together even if out of state.

Yes, I'm local to Franklin/Nashville area

Yes, I'm willing to travel (I'm out of state)

Yes, I'm willing to travel but interested in hybrid in person/remote ( I'm out of state)

Preferred Clinic Date

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Home Address

Where do you live?

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country