Patient forms

If you are beginning your exploration: Please fill out this Preliminary Screening: information we will review during our first phone call. This brief screening form will help me know how simple or complex your health situation is likely to be:  prospective-patient-brief-screen

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Forms for patients who are ready to start our work together:

Metabolic Assessment Form: This form has a copyright and can no longer be made available online. Sorry. I will need to email it to you.

Neurotransmitter Assessment Form: This form has a copyright and can no longer be made available online. Sorry. I will need to email it to you.

Child Neurotransmitter Assessment Form: This form has a copyright and can no longer be made available online. Sorry. I will need to email it to you.

Key to categories of MAF/sections of NTAF: maf-ntaf-categories-3 will explain the categories of the MAF and NTAF forms.

For someone with a long-term, complex health condition like chronic pain or chronic fatigue syndrome, please fill out these 2 questionnaires:                                                Chronic Fatigue/Pain/Infection, AutoImmune Syndrome History and    Resource Form syndrome-information-form .                            .                         .           . and                                                                                                                                          Questions on the Course of Illness & Healing,  short version: kleinmans-8-questions or the long version: questions-course-of-illness-healing …  If you are caring for someone and are filling it out for them, please use: family-course-of-illness-healing-questions . Answering these questions requires some thought and self-examination. The answers will help us chart your healing course more effectively.

Later, I may ask you to fill out this  Health History: health-history

Specialized forms for later in our work together:

Tracking allergy and food sensitivity symptoms: symptom-survey-allergies-mrt

Food Log (Abbreviations key:  BG = Blood glucose only for those monitoring glucose levels, T = thyroid dose, BM = bowel movement, sup = supplements taken, xer = exercise, sx = symptoms): Food-log-best-w-2-BG.pdf

To track sensitivity to starches and sugars: starch-sensitivity-self-test

Neurological Assessment Form: neurological_assessment_form


Insurance Work Sheet: working-with-insurance — the questions to ask your insurance company to determine what is covered.

The importance of doing testing beyond what insurance may cover:  about-testing-outside-of-insurance

Consent-release form so I can discuss your case with your other health care providers: consent-release

 

To keep track of when to take what supplement: supplement-schedule

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