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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
MM
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DD
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YYYY
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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