Neuropathy Patient

Intake Form

Please correct the errors described below.

Please fill out the application entirely and legibly.

*We will need to contact you both by phone & email. Please be sure to give us the best phone number to reach you*

Review of Symptoms

Present Health Condition

01 In order of importance, list the health problems you are most interested in getting corrected:

04 List approximately how long you have noticed these problems in your life:

Social History

Current Pain Levels

Previous Health Conditions

This is a confidential record of your medical history and pertinent personal information. The doctor reserves the right to discuss this information with medical and allied health professionals per the informed consent. Copies of this record can only be released by your written authorization.

Please give name, address, and office phone number of your primary care physician.

List ALL allergies/sensitivities to medication, food, and other items here:

Add new row

List the prescription drugs you are currently taking (or you may attach a list):

    Please upload a file

    Add new row

    List all nutritional supplements (vitamins, herbs, homeopathics, etc.) as above:

    Add new row

    Patient Quality of Life Survey

    Please take several minutes to answer these questions so we can help you get better.
    (Please check all that apply)

    07 What has that cost you? (time, money, happiness, freedom, sleep, promotion, etc.). Give 3 examples:

    Your information will be encrypted.