New Patient Survey

New Patient Survey

Please complete the following new patient survey prior to your next visit.

First Name^*

Last Name^*

Birth Date^*

Birth Time

Occupation

Email^*

Cell phone^*

Date^*

Referred by

Marital Status

what is your primary health concern or main reason for your visit?^*

Please describe your symptoms^*

Please list any other health/problems concerns that are troubling you^*

Please list your vitamins/herbs or other natural remedies^*

What prescription medications are you taking? ^*

Please list any previous surgeries^*

Have you had any car accidents or severe physical trauma?^*

Please describe your typical diet:

Breakfast^*

Lunch^*

Dinner^*

Snacks^*

Cravings^*

Beverages^*

How many hours of sleep do you get each night? ^*

How is your sleep? ^*

Difficulty Falling asleep?^*

Walking in the night?^*

Do you wake in the night to urinate?^*

Do you have any complaints with your digestion? ^*

How often do you have a bowel movement? ^*

Please list your known allergies: ^*

Please describe your hormone/menstrual history: ^*

Please list your type & frequency of exercise: ^*

What do you find stressful in your life? ^*

Who lives with you? (Any pets?) ^*

How would you describe your relationship(s) with your partner/children/parent(s)/employer?^*

Has there been any traumatic experience or major loss in your life?^*

Where have you last traveled outside the USA?^*

Have you been exposed to toxic chemicals, paints, industrial cleaners, pesticides, orchards, or golf courses?^*

Do you have silver fillings/crowns/root canals? ^*

Have you removed/replaced any mercury fillings?^*

Have you experienced reactions to any vaccinations, medications, or supplements?^*

Family medical history: ^*

Are you currently under the care of an M.D. or other health care practitioners?^*