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.)
__________________________
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 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. Dr Ben Lynch Questionnaire #1 
(Genetic influences on chronic illnesses)

 2. Dr Ben Lynch Questionnaire #2 (Advanced genetic assessment)

 3. Chronic Inflammatory Response Syndrome (CIRS) handout

 4. Chronic Inflammatory Response Syndrome (CIRS) Questionnaire

 5. Horowitz Lyme-MSIDS Questionnaire (Chronic Lyme Disease)
  • May have fatigue, nervous-system or arthritis symptoms;
  • More likely to fluctuatemove around the body, or change temporarily with antibiotics.
(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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