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  • Pre-Scheduling Intake Form

    Hello prospective patient. I'm here to serve your needs as effectively as possible. This important intake form will give me a snapshot of what's happening for you. I will review it personally and confidentially. That will help clarify if I am able to help you, and the most efficient way for us to connect and start working together so you can feel better. The intake only takes about 10 minutes, and this is a confidential, HIPAA compliant system for your privacy. I look forward to hearing from you. ---Andrew David Shiller, MD
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  • MSQ - Medical Symptom/Toxicity Questionnaire-1

    The Toxicity and Symptom Screening Questionnaire identifies symptoms that help to identify the underlying causes of illness,and helps you track your progress over time. Rate each of the following symptoms based upon your health profile for the past30 days. If you are taking after the first time, record your symptoms for the last 7 days ONLY.

  • For each of the symptoms listed below, rate their frequency and severity on a scale from 0-4 per the point scale below. If you aren't sure, make your best guess. Please give an answer to all the questions.

  •                                                    POINT SCALE
    0 = Never or almost never have the symptom
    1 = Occasionally have it, effect is not severe
    2 = Occasionally have, effect is severe
    3 = Frequently have it, effect is not severe
    4 = Frequently have it, effect is severe

     

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  •                                                    POINT SCALE
    0 = Never or almost never have the symptom
    1 = Occasionally have it, effect is not severe
    2 = Occasionally have, effect is severe
    3 = Frequently have it, effect is not severe
    4 = Frequently have it, effect is severe

     

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  •                                                    POINT SCALE
    0 = Never or almost never have the symptom
    1 = Occasionally have it, effect is not severe
    2 = Occasionally have, effect is severe
    3 = Frequently have it, effect is not severe
    4 = Frequently have it, effect is severe

     

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  • MSQ - Medical Symptom/Toxicity Questionnaire-2

    The Toxicity and Symptom Screening Questionnaire identifies symptoms that help to identify the underlying causes of illness,and helps you track your progress over time. Rate each of the following symptoms based upon your health profile for the past30 days. If you are taking after the first time, record your symptoms for the last 7 DAYS ONLY.
  •                                                    POINT SCALE
    0 = Never or almost never have the symptom
    1 = Occasionally have it, effect is not severe
    2 = Occasionally have, effect is severe
    3 = Frequently have it, effect is not severe
    4 = Frequently have it, effect is severe

     

  •  
  •                                                    POINT SCALE
    0 = Never or almost never have the symptom
    1 = Occasionally have it, effect is not severe
    2 = Occasionally have, effect is severe
    3 = Frequently have it, effect is not severe
    4 = Frequently have it, effect is severe

     

  •  
  •                                                    POINT SCALE
    0 = Never or almost never have the symptom
    1 = Occasionally have it, effect is not severe
    2 = Occasionally have, effect is severe
    3 = Frequently have it, effect is not severe
    4 = Frequently have it, effect is severe

     

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  • MSQ - Medical Symptom/Toxicity Questionnaire-3

    The Toxicity and Symptom Screening Questionnaire identifies symptoms that help to identify the underlying causes of illness,and helps you track your progress over time. Rate each of the following symptoms based upon your health profile for the past30 days. If you are taking after the first time, record your symptoms for the last 7 DAYS ONLY.
  •                                                    POINT SCALE
    0 = Never or almost never have the symptom
    1 = Occasionally have it, effect is not severe
    2 = Occasionally have, effect is severe
    3 = Frequently have it, effect is not severe
    4 = Frequently have it, effect is severe

     

  •  
  •                                                    POINT SCALE
    0 = Never or almost never have the symptom
    1 = Occasionally have it, effect is not severe
    2 = Occasionally have, effect is severe
    3 = Frequently have it, effect is not severe
    4 = Frequently have it, effect is severe
  •  
  •                                                    POINT SCALE
    0 = Never or almost never have the symptom
    1 = Occasionally have it, effect is not severe
    2 = Occasionally have, effect is severe
    3 = Frequently have it, effect is not severe
    4 = Frequently have it, effect is severe

     

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  • MSQ - Medical Symptom/Toxicity Questionnaire-4

    The Toxicity and Symptom Screening Questionnaire identifies symptoms that help to identify the underlying causes of illness,and helps you track your progress over time. Rate each of the following symptoms based upon your health profile for the past30 days. If you are taking after the first time, record your symptoms for the last 7 DAYS ONLY.
  •                                                    POINT SCALE
    0 = Never or almost never have the symptom
    1 = Occasionally have it, effect is not severe
    2 = Occasionally have, effect is severe
    3 = Frequently have it, effect is not severe
    4 = Frequently have it, effect is severe

     

  •  
  •                                                    POINT SCALE
    0 = Never or almost never have the symptom
    1 = Occasionally have it, effect is not severe
    2 = Occasionally have, effect is severe
    3 = Frequently have it, effect is not severe
    4 = Frequently have it, effect is severe

     

  •  
  •                                                    POINT SCALE
    0 = Never or almost never have the symptom
    1 = Occasionally have it, effect is not severe
    2 = Occasionally have, effect is severe
    3 = Frequently have it, effect is not severe
    4 = Frequently have it, effect is severe

     

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  • MSQ - Medical Symptom/Toxicity Questionnaire-5

    The Toxicity and Symptom Screening Questionnaire identifies symptoms that help to identify the underlying causes of illness,and helps you track your progress over time. Rate each of the following symptoms based upon your health profile for the past30 days. If you are taking after the first time, record your symptoms for the last 7 DAYS ONLY.
  •                                                    POINT SCALE
    0 = Never or almost never have the symptom
    1 = Occasionally have it, effect is not severe
    2 = Occasionally have, effect is severe
    3 = Frequently have it, effect is not severe
    4 = Frequently have it, effect is severe

     

  •  
  •                                                    POINT SCALE
    0 = Never or almost never have the symptom
    1 = Occasionally have it, effect is not severe
    2 = Occasionally have, effect is severe
    3 = Frequently have it, effect is not severe
    4 = Frequently have it, effect is severe

     

  •  
  •                                                    POINT SCALE
    0 = Never or almost never have the symptom
    1 = Occasionally have it, effect is not severe
    2 = Occasionally have, effect is severe
    3 = Frequently have it, effect is not severe
    4 = Frequently have it, effect is severe

     

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