Form Instructions
- Please complete all forms as best as you can. Make sure you sign and date the forms as required.
- To expedite our initial encounter complete all forms and bring them with you to our first visit.
- Text, call or email me to set up this first appointment if we did not already do so.
I look forward to being of service to you.
Yours in health,
Michael Tereo, D.C.
PATIENT INTAKE FORM
INFORMED CONSENT
DIGESTIVE SCREENING QUESTIONNAIRE
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.
HOW MUCH TO EAT
This poster demonstrates meal size and portion ratios.
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.
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.
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.