Dr. Murphree's New Patient Health Questionnaire
*Please note: Phone consultations are NOT covered by insurance. New patient consultations are $129.
First and Last Name *
Your answer
Today's Date
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Home Phone *
Your answer
Cell Phone (or other alternate phone number)
Your answer
Address *
Your answer
Apt #, Unit #, Suite #
Your answer
City, State *
Your answer
Zip Code *
Your answer
Date of Birth *
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DD
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Email Address *
Your answer
Height *
Your answer
Weight *
Your answer
Do you have Dr. Murphree's Treating and Beating Fibromyalgia & Chronic Fatigue Syndrome book? *
If you have not, please follow the link below for access to more information about his book, and links to purchase his paperback and eBooks:
Have you watched Dr. Murphree's Fibromyalgia Video Series? *
If you have not, please follow the link below to access all of Dr. Murphree's FREE Videos to watch them prior to submitting this paperwork:
What kind of work do you do? *
Your answer
Are you on disability? *
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