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Patient Name
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Your answer
Today's date:
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Email Address
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Your answer
How did you find me? If referral, who referred you?
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Your answer
Date of Birth
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Birth Sex
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Female
Male
Other:
Address
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Your answer
City
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State
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Parent/Guardian Name (if patient is a minor)
Your answer
Phone Number
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Your answer
Is it okay if I leave a voicemail?
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No
Chief Complaints (be as specific as you’d like and list in order of importance)
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Your answer
Do you have a primary care physician? (Dr. Wakely is a specialist and although he can provide primary care, he requires that you have a PCP in your local area.)
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Yes
No
Other:
Name of PCP and Name of Practice
Your answer
Please list the prescription medications that you take. If none, write "n/a".
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Your answer
What potential obstacles do you foresee in addressing the lifestyle factors undermining your health and in adhering to the therapeutic protocols I'll be prescribing for you?
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Your answer
Who do you know that will sincerely support you with the positive lifestyle changes you'll be making?
Your answer
What do you value besides your health?
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