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New Patient Questionnaire

We at WellBeingMD are excited about your interest in our practice. To be sure we align your goals early, we have provided this Brief Secured New Patient Questionnaire. Please complete the form and a member of our staff will contact you regarding your responses.


1. List 5 of your top health concerns or goals.


2. List all practitioners and treatments, including self-care, that have been used to resolve these concerns:


3. What are you willing to do to get better?


4. What are you going to reward yourself with when these health concerns are resolved or improved?


This document has been reviewed with me by WellBeingMD, LTD, John R Principe, MD and I understand and am willing to comply with the recommendations to improve my health.

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