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New Client Intake Form
Please take your time in completing this questionnaire.

Once the forms are submitted, the intake forms will be reviewed and you will be contacted to move forward with the New Patient process.

You will receive an email confirmation of receipt of your form.

The review process typically takes about 48-72 hours, and may vary due to the volume of intakes received.

Thank you !

How does the process work?
First: You must apply to become a patient. (fill out the rest of this form)
Please note: we cannot accept all patients

Second: Have an initial History and Exam visit with Dr. Chris

Third: Your Report of Findings with lab results and any recommendations


If accepted, our staff will contact you promptly to set up your first visit. During your Initial History and Exam visit, Dr. Chris will review:
Your health and medical history
Your diet and lifestyle
Body systems affected by your problem
The history, onset and key characteristics of your illness

Dr. Chris will explain what testing should be performed to pinpoint the cause of your problem and to help direct Dr. Chris in formulating a customized game plan for you. The goal here is to uncover the underlying cause of your problem

Please note if you have insurance Dr. Chris will do his best to do as much of the lab testing through your insurance as possible.

During your second visit with Dr. Chris he will provide you with a Report of Findings. This is where Dr. Chris will:
Explain what he believes is causing your problem
An overview of your customized restorative program which will include
An initial diet plan
An initial lifestyle plan
Supplementation and other needed resources
Provide a time frame as to how long your recover may take

During Follow-Up Visits Dr. Chris will:
Monitor your response to your program
Explain any new lab findings
Adjust recommendations based upon lab findings and your level of responsiveness
Order any follow up testing needed as treatment progresses
Answer any questions you may have or wish to discuss

First Name *
Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Age *
Gender *
Mailing Address *
Preferred contact phone number *
How did you hear about us or who should we thank for the referral? *
On a scale of 1-10, How motivated are you to get well? *
None
Extremely
Please list your top 3-5 symptoms, in order of importance. Include how frequent you experience each symptom and how severe it is (severity 1=mild, 10=severe). Please note things like “SIBO” or “Adrenal fatigue” or “hypothyroid” or “inflammation” are not symptoms. Bloating, gas, fatigue, insomnia and joint pain are symptoms.
Symptom #1 *
Symptom #1 Frequency *
Symptom #1 Severity (at it's worst) *
hardly notice it
Severe
Symptom #1 What helps? *
Symptom #1 What makes it worse? *
Symptom #2 *
Symptom #2 Frequency *
Symptom #2 Severity (at it's worst)
hardly notice it
Severe
Symptom #2 What helps? *
Symptom #2 What makes it worse? *
Symptom #3 *
Symptom #3 Frequency *
Symptom #3 Severity (at it's worst) *
hardly notice it
Severe
Symptom #3 What helps? *
Symptom #3 What makes it worse? *
Symptom #4
Symptom #4 Frequency
Symptom #4 Severity (at it's worst)
hardly notice it
Severe
Symptom #4 What helps?
Symptom #4 What makes it worse?
Symptom #5
Symptom #5 Frequency
Symptom #5 Severity (at it's worst)
hardly notice it
Severe
Symptom #5 What helps?
Symptom #5 What makes it worse?
Are you concerned about any conditions or anything else. For example are you suspicious you have SIBO or hypothyroid? Or, are you trying to prevent something, like heart disease or cancer? *
Is there anything else you would like us to know during your initial case review ? *Please note, a more detailed form will be required to be filled out prior to the Initial Exam to gather additional information regarding your specific case. *
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