Dr. Antonucci's New Patient Application

  • New Patient Application

    This questionnaire will better help the doctor understand if he's a good fit for your health goals. Your answers will determine if the doctor accepts your case or will make an appropriate referral. Please take your time to ensure its accuracy and completeness.
  • What best describes you?
  • Your relationship to the patient
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  • While it is nearly an impossible feat to create a form that is ideal for every patient's situation, we have embedded some conditional logic in this form to remove questions that you may not be able to answer (eg: symptoms). However, there are some questions that we would like you to attempt to answer to the best of your ability for the patient, and they have not been removed. Thank you for understanding.

  • Patient’ Sex (Confirmation)*
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  • Is the patient able and willing to communicate their symptoms and feelings with you?
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  • Your symptoms...*
  • Your symptoms...*
  • Are there factors that make your symptoms better or worse?*
  • Which of the following make your symptoms BETTER?*
  • Which of the following makes your symptoms WORSE?*
  • Which of the following interventions have you tried? Select all that apply

  • For the following, please indicate approximately how much the following therapies affected your current challenge. 0 equals no change. To the left indicates that it made you worse. (0 to -100). To the right indicates it helped (0 to 100)

  • Have you experienced any emotional traumas in your past?*
  • Employment Status*
  • Are you trying to get pregnant?*
  • Is it possible that you might be pregnant?*
  • Select the reason it is not possible to be pregnant*
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  • Please read each statement carefully and select the statement(s) that are TRUE for you.*
  • Check which of the following that you've had.*
  • Check which life-threatening allergies that you have, if any.*
  • Are you familiar with your maternal (mother's) family history?
  • Are you familiar with your paternal (father's) family history?
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