Online Questionnaire Forms






("Appointment Online"
shows availability up to 
30 days in advance.)
(Please send a message if you have difficulty logging in.)

NOTE:
(Always use your primary
provider or emergency
department/911 for any
urgent or emergency
medical problems.)
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Click on the Emerson 
online dispensary
 
below for high-quality 
supplements, 20% 
discount for my patients,
after appropriate lab
testing and assessment.

Wellevate Logo
(EmersonWellevate Helpline is 
855-935-5382 Eastern Time,
M-F 8:30-8, & Sat 9-5.)

________________________

ALTERNATIVE DISPENSARY:

Click on the Fullscript 
online dispensary

for high-quality 
supplements, 20% 
discount for my patients,
after appropriate lab
testing and assessment.

(Fullscript helpline is
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 over 3 days in advance, rather than from memory at the last minute)
Also, please download Diet for Good Health,your guidelines for healthy eating.
(With today's decreasing nutritional quality and increasing environmental  pollution, we have to work harder to maintain optimum health.)

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Handouts & online resources:

Food Intolerances: See http://www.glutenfreeandmore.com for advice, support, and free downloadable recipes for people living with food sensitivities such as celiac disease, non-celiac gluten sensitivity, or dairy (casein). There is advice on gluten-free food shopping, hidden gluten-containing additives, and allergy-friendly restaurant guidance. A magazine subscription is available (6 issues/year).

Magnesium and Vitamin C Dosing (optimize for chronic diseases)

SPECIAL HANDOUTS:

Inflammation & “CIRS”:
Dr Ben Lynch Questionnaire #1 (Genetic influences on chronic illnesses) 
 (Please see the Health Info page for other handouts and information.)
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For help in changing your dietary habits:
Jeanne Peters, RD, Nutritionist, at 819 N Harbor Dr, Suite 310, Redondo Beach
(310) 373-7830
Rene von Gunten, NTP, CPT, at 2066½ Hermosa Ave, Hermosa Beach
(424) 259-2680

For help in coping with stress:
Crossroads Institute for Psychotherapy and Assessment, 2601 Airport Drive, #135, Torrance
(424) 201-1600

 
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