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.
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.
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.
HOMEWORK PAGE (English and Spanish versions)
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.
YEAST QUESTIONNAIRE
THIAMINE DEFICIENCY QUESTIONNAIRE
thiamine-deficiency-questionaire.pdf
