Newbridge Health & Wellness
This is intended to be a brief introductory form. If you decide to become a patient with us, you will have a second and more extensive form to fill out.
Patient First Name *
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Patient Last Name *
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Patient Date of Birth *
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Patient Gender *
Address
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City
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State
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Postal/ZIP Code
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Patient Phone Number *
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Email address *
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Caretaker (If applicable) First Name
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Caretaker (if applicable) Last Name
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Caretaker Relationship to Patient
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How did you hear about us?
If someone referred you, please provide their name:
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What is your main interest or reason for contacting us?
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Please check the goals for your care:
Are you interested in seeing an additional provider for:
What diagnoses (list all) have you or your child been given from other health care practitioners (if you don't have a diagnosis/diagnoses, what are your main symptoms or concerns)?
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How many other functional medicine health care providers have you seen?
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Please list all of the treatments and approaches you have used/tried in the past and what has been good for you (or worked for you) or not?
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What is your / your child's current eating style / food plan?
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What other healthy lifestyle practices do you integrate into your / your family's life?
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How long have you / your child been ill or affected?
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Please list the specific health goals that you would like us to help you with?
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Are there specific treatments or modalities that you are interested in?
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Is there a specific provider or staff member that you are interested in seeing?
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Please rate your understanding of integrative and functional medicine or biomedical approaches?
Other comments or questions?
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