Lifestyle Docs - Publicforms

Available Forms

I. New Patient Registration Form, Required II Uninsured New Patient Registration Form III. Patient Medical History, Required IV. Request an Appointment IV. Review of Systems IX. Spanish Patient Medical History, Required V. Lifestyle History, Optional V. Nutrition & Dietary Habits, Optional VI. Detailed Autoimmune Disease History, Optional VI. Detailed Diabetes History, Optional VI. Detailed Digestive Health History, Optional VI. Detailed Hypertension History Optional VI. Detailed Weight History, Optional VII. Spanish New Patient Registration Form VII. Spanish Uninsured New Patient Registration Form

VI. Detailed Autoimmune Disease History, Optional

Name *

Please, enter your first name followed by last name

Sex *

Male

Female

Date of Birth *

Auto Immune History

What auto immune disease do you have? *

How was the diagnosis made? *

Blood work

Biopsy

Clinical symptoms

Other

Please select all that apply

How long have you had this auto immune disease? *

What are your symptoms related to the auto immune condition? *

Please list all

Which symptoms bother you most?

How often do you experience these symptoms? *

Nearly all the time

Several times a day

Only during a certain time of day

Several times a week

Several times a month

Are your symptoms getting worse or are they the same as 6 months ago? *

Same

Worse

Better

What limitations do you have as a result of this disease? *

Physical limitations; trouble walking, limb weakness, vision problems, difficulty with intimacy

Dietary limitations; unable to tolerate certain foods, unable to eat out

Work limitations

Social limitations

Other limitations not listed

No limitations

Please select all that apply

What medicines are you currently taking? *

Please include medicine, dosage and duration

How effective are the medicines at relieving/controlling your symptoms? *

Work very well

Work most of the time

Not working well

What side effects do you have from the medications?

Please list all

What else, besides medicine, are you doing to help reduce symptoms?

Example: remove certain food groups, participating in strength, relaxation or rehabilitation classes, etc

Do you believe diet and lifestyle can affect your disease? *

Yes

Unsure

Do you think your auto immune disease can be reversed with diet and lifestyle? *

Yes

Unsure

Health Goals

Are you interested in reducing or eliminating your condition through diet and lifestyle changes? *

Very interested

Interested

Neutral

Not very interested

Which medication would you like to discontinue first?

Why do you want to get off your medications? *

Examples: long term financial cost, negative side effects, long term risk, less time spent visiting doctors, etc

How confident are you that you will succeed in making diet and lifestyle changes without any outside support? *

Very confident

Confident

Somewhat doubtful

Doubtful

How confident are you that you will succeed in making diet and lifestyle changes with support from Lifestyle Docs? *

Very confident

Confident

Somewhat doubtful

Doubtful

What is the most important change you would like to see by adopting a healthier diet and lifestyle *

Are you open to using water fasting, juicing or a raw diet for short periods of time to support health and healing? *

Are there any unusual stressors in your life right now that may hinder your efforts to reduce/eliminate your condition(s)?

Readiness today *

I am ready to drastically change my diet and lifestyle to get healthier and work on other health goals

I am interested in changing my diet and lifestyle but at a slow and sustained pace.

I am interested in changing my diet and lifestyle in the near future

I am interested in changing my diet and lifestyle in the next 6 months

I am not quite ready but see the value in changing my diet and lifestyle.

* Required field