New Patient Inquiry Form
Our practice strives to provide the best one-on-one and personalized care tailored to your individual needs. Kindly fill out our questionnaire so that we may learn about you as it relates to our program offerings.
Email address *
Name *
Gender *
Date of birth *
Please describe the nature of your health concerns. *
How long have these health concerns been active? *
Have you become discouraged or distressed by these health problems? *
Do your health problems affect your...
(severity on a scale from 0 to 10, with 0 the least and 10 the most)
Work *
Family life *
Recreational activities *
Sexual function *
Relationships with friends *
What factors do you believe have contributed to creating these health issues? *
Left untended, where do you anticipate these health problems will take you? How do you imagine your life in 3-5 years if these health issues are not addressed? *
What are your goals in working with the Plum Spring Clinic (limited/short-term/resolution of symptoms or more holistic functional goals including lifestyle modifications and wellness)? *
How would you rate the importance of resolving your health problems? *
Is there anything else that you would like us to know about you or your health concerns?
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