Online Questionnaire Forms






("Appointment Online"
shows availability up to 
30 days in advance.)


NOTE:
(Always use your primary
provider or emergency
department/911 for any
urgent or emergency
medical problems.)


Click on this one-stop
online shop
(
Fullscript)
below
for high-quality
supplements,
20%
discount
for my patients,
for your 
customized
treatment
plan after
appropriate lab
testing
and assessment
.
Or, call their
Patient Ordering Line
at 1-866-807-3828
(Eastern Time)
M-Th 9-8, & F-Sat 9-5.

 
NEW PATIENT PAPERWORK:
Please download and complete these 3 forms before your first visit, and bring with you:
  1. New-Patient Registration
  2. Medical History Questionnaire
  3. 3-Day Diet Diary (fill out as you go rather than from memory at the last minute)
Also, please download Diet for Good Health (your guidelines for healthy eating)



SPECIAL QUESTIONNAIRES (only if directed):
 1. Ziem Protocol For Chemical Injuries:
               (toxic exposures or multiple chemical sensitivities)
             (See http://www.chemicalinjury.net/medicalcare.htm for more information)

 2. Chronic Lyme Disease (can mimic Chemical Injury):
    • May have fatigue, nervous-system or arthritis symptoms;
    • More likely to fluctuatemove around the body, or change temporarily with antibiotics.



For info on The Bredesen Protocol™
(For Cognitive Decline in SCI, MCI, and early Alzheimer’s disease)


(Please see the 
Health Info page for other handouts and information.)
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