Diabetes New Patient Questionnaire
Julie Lachman, ND, Kailyn Galloway, ND, Tosha Kadakia, PA-C/Don Pham, DO (collaborating physician)
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Sex
Please Select
Male
Female
N/A
Height (inches)
Weight (pounds)
Marital Status
Please Select
Single
Married
Divorced
Legally separated
Widowed
Contact Number:
E-mail
example@example.com
Is that number a cell number or a land line?
cell
land line
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Taking any medications, currently?
Yes
No
Please list any here
Are you able to: take supplements 1-3 times daily (pills, powders, liquids, as needed) and call the office with any questions?
Are you looking for virtual visits or in-person visits?
If you live locally, are you willing to come to the office multiple times weekly for therapies to help lower pain, treat neuropathy, and balance sugars, when you start your program?
Submit
Should be Empty: