• New Patient Paperwork

    New Patient Paperwork

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  • Gender*
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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • How did you hear about us?*
  • Request prayer and/or spiritual counseling?
  • Browse Files
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  • Health Appraisal Questionnaire

    Health Appraisal Questionnaire

  • Is it your 1st time completing this questionnaire?*

  • Part 1

  • Check and list any of the following medications (and doses) you are taking:
  • Check if you eat, drink or use the following
  • Check if these apply to you:
  • Are you now or have you been exposed to chemicals at home or work?
  • Are you now or have you been exposed to second hand smoke?

  • INSTRUCTIONS: Check the number which best describes the intensity of your symptoms for the past 3 months. If you don't know the answer to a question, leave it blank. (0 for symptom not present, 1 for Mild, 2 for Moderate, 3 for Severe)

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  • This section is for Males and Females. Please check the symptoms that apply to you.

  • Part 10 Section F: Hormone Balance Test Group 1

  • If you have checked 2 or more boxes in this group, find out what type of hormonal imbalance you may have below.


    1. SYMPTOM GROUP 1 Progesterone deficiency: This is the most common hormone imbalance among women of all ages. You may need to change your diet, ask your doctor about getting off of synthetic hormones and you may need to use some progesterone cream.

  • Part 10 Section F: Hormone Balance Test Group 2

  • If you have checked 2 or more boxes in this group, find out what type of hormonal imbalance you may have below.


    2. SYMPTOM GROUP 2 Estrogen deficiency: This hormone imbalance is most common in menopausal women; especially if you are petite and/or slim. You may need to make some special changes to your diet; take some women's herbs; and some women may even need natural estrogen.

  • Part 10 Section F: Hormone Balance Test Group 3

  • If you have checked 2 or more boxes in this group, find out what type of hormonal imbalance you may have below.


    3. SYMPTOM GROUP 3 Excess estrogen: In women, this is most often solved by getting off of the conventional hormones (with your primary care physician's approval) most often prescribed by doctors for menopausal women.

  • Part 10 Section F: Hormone Balance Test Group 4

  • If you have checked 2 or more boxes in this group, find out what type of hormonal imbalance you may have below.


    4. SYMPTOM GROUP 4 Estrogen dominance: This is caused when you don't have enough progesterone to balance the effects of estrogen. Thus, you can have low estrogen, but if you have even lower progesterone you may experience symptoms of estrogen dominance. Many women between the ages of 40 and 50 suffer from estrogen dominance.

  • Part 10 Section F: Hormone Balance Test Group 5

  • If you have checked 2 or more boxes in this group, find out what type of hormonal imbalance you may have below.


    5. SYMPTOM GROUP 5 Excess androgens (male hormones): This is most often caused by too much sugar and simple carbohydrates in the diet and is often found in women who have polycystic ovary syndrome (PCOS)

  • Part 10 Section F: Hormone Balance Test Group 6

  • If you have checked 2 or more boxes in this group, find out what type of hormonal imbalance you may have below.


    6. SYMPTOM GROUP 6 Cortisol deficiency: this is caused by tired adrenals, which is usually caused by chronic stress or chronic inflammation.

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  • Part 13B (Sleep Apnea)

    Sleep apnea is a common disorder. Experts say it affects about eighteen million Americans. People with sleep apnea stop breathing for brief periods while they sleep. They may awaken for a few seconds as they struggle to breathe. The next day, the sleeper may not remember what happened. Signs of the disorder include sleepiness during the day and restless sleep. Some people make rough sounds while they sleep. More men have sleep apnea than women do. It is also common in older adults and in persons who are heavy

  • Check the numbers of the comments that apply to you:

  • If you circled 5 or more symptoms, you could have OSA (obstructive sleep apnea). The risks of OSA include heart attacks, strokes, impotence, irregular heartbeat, high blood pressure and heart disease.

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  • 1.1 CURRENT DENTAL FILLINGS (if you're not sure, please ignore)

  • Amalgam

  • Gold

  • Titanium

  • Composites

  • Metal-bond ceramic

  • Cobalt-crown

  • Non-metallic ceramic

  • 1.2 ROOT CANAL FILLINGS

  • Amalgam

  • Gutta Percha

  • Calcium Hydroxide

  • Other

  • Gene HAQ

  • MTHFR
  • DAO
  • COMT (slow)
  • COMT (fast)
  • MAOA (slow)
  • MAOA (fast)
  • GST/GPX
  • NOS3
  • PEMT
  • Limbic System Questionnaire

    Limbic System Questionnaire

  • Do you suffer from 'brain fog' or unexplained headaches?*
  • Do you suffer from low energy?*
  • Do you suffer from chronic joint and/ or muscle pain?*
  • Do you find yourself constantly 'body checking' for symptoms of pain or discomfort?*
  • Do you have a heightened sense of smell or taste?*
  • Do you have other heightened sensory perceptions, such as light, sound or electromagnetic sensitivities?*
  • Do perfumes or other chemical products (e.g. household cleaners, personal hygiene products, paint, adhesives, new textiles or carpets, etc.) give you headaches or make you feel nauseous or lightheaded?*
  • Do you get noticeably irritable, anxious, or upset when around specific scents?*
  • Have you had your home, office, or other space renovated recently?*
  • Do you suffer from anxiety or panic attacks?*
  • Do you purposely avoid going to specific places or doing specific things because of your health condition or because of the potential health risks?*
  • Do you have sleep-related issues?*
  • Are you limited in what you can do physically due to your health issues?*
  • Do you have a number of food sensitivities?*
  • Are you unable to take prescribed medications?*
  • Have your health conditions affected your job?*
  • Have your health conditions affected your relationships with your friends and family?*
  • Do you have problems accessing medical care due to your sensitivities?*
  • Have you been to see a number of practitioners that were unable to diagnosis your condition or effectively treat it?*
  • Do you experience pronounced mood swings?*
  • Do you find it difficult to focus or concentrate?*
  • Do you dwell on past negative events?*
  • Do you find yourself expecting negative outcomes?*
  • Do you have short-term memory problems?*
  • Do you worry a lot?*
  • Do you often feel depressed?*
  • Do you still experience symptoms of illness despite the fact that you live in a healthy home?*
  • Have you tried detoxification treatments and nutritional supplements yet still find that you are symptomatic?*

  • Part 2: BIOTOXINS QUESTIONNAIRE (Bartonella Symptoms)

  • Biotoxins

  • Part 2A: BIOTOXIN CIRS QUESTIONNAIRE Mold & CIRS (Chronic Inflammatory Response Syndrome)

  • Mold Symptoms

  • Rate each of the symptoms to the best of your ability based on the last 6 months. For Yes/No answers, circle the number next to your answer, if there is a number.

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  • If you checked any items below, you're at an increased risk of heavy metal toxicity.

  • Are any of the following current or past occupations or hobbies?
  • In-Clinic Policies

    In-Clinic Policies

  • • SCENT POLICY: For the sake of our chemically sensitive patients, please do NOT wear perfume, cologne, or strongly scented soaps or lotions to your appointment.

    • We do not accept insurance. We do not provide diagnostic codes for you to file with your insurance company.

    • We do not file or provide information pertaining to disability claims or any other government organization. That needs to be provided by your PCP.

    • We do not process insurance claims as most insurance companies don't pay for Naturopathic services. We do, however, offer payment plans, accept Health Savings Accounts, Care Credit & United Medical Credit.

    • There are NO REFUNDS for any LAB TESTS or NUTRITIONAL PRODUCTS.

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