Health Questionnaire – Repeat Visits

If this is your first visit, please go back and fill out the Health Questionnaire – Initial Visit form. This form is for repeat visits only.

Please complete any relevant information below. If nothing has changed, please type “N/A” or “no changes” in the box. This way, during your consultation, we will be able to spend more time discussing your current concerns. Thank you!

Name *

First

Last

Your Cell Number *

May I text you? *YesNo

Email *

Current Health Concern – Please provide as much detail as you can. *Be sure to include "URGENT" if this is an urgent acute consult request. *

Have there been any changes since our last consultation? (Changes in medications, supplements, diet, exercise, etc, that I may need to know) *

Have you had any major dental work (fillings, extractions, crowns, root canals or an abcess) since our last consultation? *<select answer>YesNoI don't know

If yes, please briefly describe.

IF YOU HAVE BLOOD TEST RESULTS OR OTHER STUDIES THAT YOU WOULD LIKE TO SHARE, PLEASE UPLOAD THOSE IN THE SPACE BELOW.

If you have issues uploading files, respond to the Calendly confirmation email you will receive after scheduling your appointment (next steps) and attach the files there.

File Upload

Click or drag files to this area to upload. You can upload up to 5 files.

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