Prior to Your First Visit

Instructions for Forms to be completed prior to the First Visit

All of the forms are available on our web page, in both Word and Excel formats. If you plan on mailing or faxing the forms, the Word format form should be printed out, to be completed using a pen. If you want to use e-mail, which of course is faster, then use the Excel formatted form and save it to a working location. You can then complete the form, attach it to an e-mail, and send it to our e-mail address.

The New Patient Information Form: This form needs to be completely filled out.

Dietary Intake for past 2 days before appointment: Please indicate any and all foods and beverages, including approximate quantities, taken over the last 2 days. Be as specific as possible. The accuracy with which this is done determines our ability to understand and analyze your data.

The Symptom Survey Form: Although this form takes some time and effort to complete, it helps tremendously in our nutritional and physical assessment of your present health status. Please read these instructions carefully and follow them as explained.

There are two and half pages to this form. Make sure that you have completed ALL of them.

Every numbered item needs to be evaluated and assessed as to whether or not it applies to you. If it does not apply then do not circle any of the numbers and go on to the next question. If you are using the Excel form (e-mail version), then place the appropriate number in the box just to the left of the symptom as described below.

If the item does apply you must indicate the severity of the symptom by placing the correct number which applies to you in the box provided.

The numbering scale that is to be used is as follows:
1 means mild or occasional
2 means moderate or somewhat more often than occasional
3 means severe, frequent, most of the time, or all of the time
If the symptom does not apply leave it blank or do not circle any number.

Be sure to indicate the five main physical complaints you have in order of their importance.

Upon completion of both forms please put them in the mail immediately, or if you want to expedite things you can bring them in for us so that we can schedule an appointment right away. If you e-mail them be sure to call and let us know so that we can process them as soon as possible If you have any questions please call us at 217-531-2711.

Thank you,

Liza
Patient Advocate