• 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?
  • Below are a list of symptoms that people might experience. Please read each symptom and select the option that best represents the severity of each symptom over the past 7 days. You must provide a response to each symptom.*
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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)

  • Physical Therapy*
  • Chiropractic*
  • Functional Neurology*
  • Occupational Therapy*
  • Vestibular Rehabilitation*
  • Vision Therapy*
  • Psychotherapy/Hypnosis*
  • Neurofeedback*
  • Medications*
  • Supplements*
  • Hyperbaric Oxygen Therapy*
  • Stem Cells*
  • Yoga/Pilates*
  • Accupuncture*
  • Meditation*
  • Exercise*
  • Diet*
  • Speech/Feeding*
  • Massage/Myofascial*
  • Have you experienced any emotional traumas in your past?*
  • Supplements/Vitamins (You will need to put "N/A" if none apply)*
  • Medications (You will need to put "N/A" if none apply)*
  • 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*
  • Cardiovacular Health*
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  • Skin Health*
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  • EENT Health*
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  • Genitourinary Health (General)*
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  • Genitourinary Health (Male)*
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  • Genitourinary Health (Female)*
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  • Female Questions 2
  • Metabolic Health*
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  • Musculoskeletal Health*
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  • Neurological Health*
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  • Respiratory Health*
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  • Endocrine Health*
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  • Psychological Health*
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  • GI/Digestive Health*
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  • Please read each statement carefully and select the statement(s) that are TRUE for you.*
  • Please list all surgeries in which you were administered general anesthesia ("put to sleep"). You will need to put "N/A" if none apply.*
  • 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?
  • Family History
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