• New Patient Paperwork

    New Patient Paperwork

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  • Health Appraisal Questionnaire

    Health Appraisal Questionnaire

  • Part 1

  • 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.

  • 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.

  • 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.

  • 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.

  • 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.

  • 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)

  • 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

  • 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

  • Limbic System Questionnaire

    Limbic System Questionnaire

  • Part 2: BIOTOXINS QUESTIONNAIRE (Bartonella Symptoms)

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

  • 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.

  • 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, accept Health Savings Accounts, Care Credit & United Medical Credit.

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

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