The Biber Protocol® Intake Form

The Biber Protocol® Intake Form

Putting the Care back in HealthCare!
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
DOB and age
Primary complaint
Was there any specific event that may have caused your current complaint?
Please describe your problem providing as much detail as you can:
Have you received treatment for this in the past? If so, please list the types of treatment you received and if they were successful.
Who have you seen to address this problem?

Other
What tests or procedures have you had related to this problem?
Can you provide copies of any of the reports or doctors notes of the tests/procedures performed?
Medical history; please check all that apply to you:
If you have a history of cancer, what type of cancer was it and what treatment did you have?
Please list any other relevant medical conditions not listed above.
What are your goals related to your condition? What do you hope to achieve?
How much has your problem affected your quality of life?
In what specific ways has your condition affected your day to day activities?
Do you have any religious or cultural beliefs that might influence the way you prefer to receive care?
How do you prefer to learn new information? Check all that apply:
Have you had any surgery related to your current condition? If so please provide type of surgery and date:
Do you have any pain associated with your problem?
Please list all current medications and reasons for taking
Is there anything else you would like to add about your problem?
Should be Empty: