Patient Information Form

PERSONAL INFORMATION

Introductory Patient Information
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Have you or your family experienced any major life changes? *
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Have you experienced any major losses in life? *
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Do you have learning difficulties? *

COMPLAINTS/CONCERNS

Please list your chief symptoms in order of decreasing severity. Please note when the symptom started.
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How much time have you lost from work or school in the last year? *

PAST MEDICAL & SURGICAL HISTORY

CHILDHOOD HEALTH HISTORY

Did you require more than 5 courses of antibiotics as a child (ages 0-12)? *

FEMALE MEDICAL HISTORY (for women only)

ESTABLISHING HEALTH GOALS

 

PERSONAL MESSAGE

I have read something interesting: “The definition of insanity is to keep doing the same thing and expecting different results”.  If you keep following the same course of treatment you have been following will your results really change? Have you ever wondered if you are on the right path to achieving optimal health? Sometimes it requires taking a new and improved road to reach your destination.

Most people I ask tell me they’re made the decision to change. But how many people have truly decided to change? Very few! Why? Because there is a big difference between deciding something and having “reasons” to actually do it.

When you have made a decision to make a change and you know your reasons, you create an internal power that can propel you to achieving health and wellness. 

 
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