In order to provide you the best possible service, please complete this form. There is certain information that the Doctor needs to be able to advise you. Sections marked with a RED ASTERISKS are mandatory.

Patient Data

Current Complaints

How Does Your Condition Limit Your Daily Life?

What have you tried to fix this condition?

What are your goals for your long term health?

If you were to find and treat the CAUSE of your condition, what would the likely outcome be?

If you were to find and treat SYMPTOMS ONLY AND NOT THE CAUSE of your condition, what would the likely outcome be?

Is that what has been happening to you?

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