Patient Forms

I look forward to being of service to you.

Yours in health,
Michael Tereo, D.C.

PATIENT INTAKE FORM

New Patient Form

Patient History Form

INFORMED CONSENT

Consent Exam Form

DIGESTIVE SCREENING QUESTIONNAIRE

Digestive 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

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