PATIENT INTAKE FORM

This form has several components which include present complaint; past health history; and how well you tolerate your activities of daily living. Please print the form and complete as neatly and fully as possible. Be sure to bring the completed form with you for your initial consultation and examination.

NEW PATIENT INTAKE FORM

 

MOTOR VEHICLE (CAR ACCIDENT) INTAKE FORM

This form is best utilized when involved in a car accident. The form has detailed components which helps us determine best how to help you.

MVA HISTORY FORM

 

DAILY RECORD OF FOOD INTAKE

This form is a food diary which helps us gain insight into your nutritional intake as well as other essential biological functions. Download this tool and follow the easy instructions then bring the completed form to the office for assessment.

DAILY RECORD FOOD INTAKE

 

HOMEWORK PAGE (English and Spanish versions)

HOMEWORK

 

HOW MUCH TO EAT

This poster demonstrates meal size and portion ratios.

HOW MUCH 2 EAT

 

SYMPTOM ASSESSMENT FORM

This form is best utilized when you are interested in supporting health issues. The form has detailed components which helps us determine best how to help you.

SYSTEMS ASSESSMENT FORM

 

HEADACHE AND MIGRAINE QUESTIONNAIRE

This form is best utilized when headaches are part of your health issues. There are many types of headaches and this form has detailed components which helps us determine best how to help you.

HEADACHE AND MIGRAINE QUESTIONNAIRE

 

SLEEP QUESTIONNAIRE

This form is best utilized when difficulty falling or staying asleep is one of your health issues. The form has detailed components which helps us determine best how to help you.

SLEEP QUESTIONNAIRE

 

TOXICITY QUESTIONNAIRE

This form is utilized for pre and post assessment of the 10-Day and 28-Day Detox Balance Program as well as the 21-Day Purification Weight Management Program. This is a good form to assess your current toxicity levels and which body systems may be affected by your current lifestyle.

TOXICITY QUESTIONNAIRE

 

YEAST QUESTIONNAIRE

YEAST QUESTIONNAIRE

 

THIAMINE DEFICIENCY QUESTIONNAIRE

THIAMINE DEFICIENCY QUESTIONNAIRE