Patient Forms
Please read these paragraphs then print and fill out the
patient forms we will need to help you. This will save you money and allow us to provide you the highest level of care.
All new Patients, please fill out the Nutritional Assessment Questionnaire (NAQ) and mail or fax it to us at least 2 days ahead of your first appointment so that we can get it run through the computer analysis and have the results available. Please remember to use numbers 1, 2, and 3 all the way through this form, but you can leave zeroes blank.
The Amen Attention Deficit form only needs to be filled out if, after you read it online, you know you will have more than six 3's or 4's. If so, please print it out and write in the SELF column the number that defines your response to each question on the four pages, and also have someone who knows you well fill out their perceptions in the OTHER column. Please bring the filled in questionnaire along with you to your first appointment.
The Medicare form needs to be filled out only by those people who are Medicare recipients. Please fill it out and send or fax in with the NAQ, as it needs to be dated in advance of your first appointment.
The other 3 forms, the Practice Information, Patient Registration, and Health History, should be filled out by everyone and brought along to the first appointment. Also, it is very helpful to bring copies of your original labs that we may keep for your chart here, but if you are unable to make your copies, we do have a copier in the office. We do not need the interpretations of the tests, just the results- usually the first page of a multi-page explanation.
 Click here to download Adobe Acrobat reader.
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