Patient Forms
We work hard to ensure our current patients have access to their records and that new patients are able to provide us with vital information easily. This page has links to intake forms, questionnaires, and medical history requests for New and Established Patients.
Patient Forms
Below are forms and questionnaires that New Patients & Established Patients should use to provide information prior to each office visit. Contact us if you are unsure which forms you need to complete before your next visit.
Notice
Forms need to be completed at least 48 hours prior to initial appointment and 6 hours before follow-up visit appointments.
New Patients
New Patient Forms
Below are the forms that should be filled out by new patients
New Patient Demographics Form
Before your first appointment, we require that all new patients complete our patient intake questionnaire. It's online, easy, and can be done in minutes.
New Patient CIRS History Form
CIRS patients only: Please complete the New Patient CIRS History Form prior to your first appointment. This will help us assess your relative CIRS risk and better undertsand your symptoms and risk of mold and biotoxin related exposure.
New Patient Combined CIRS/Controlled Substances
If you are suffering multiple conditions related to CIRS, Substance Abuse or Chronic Pain we are truly sorry. To help better diagnose and treat your concerns, we ask that you complete our New Patient Combined Medical History Form prior to your first visit. This helps ensure we're able to address your concerns swiftly and accurately.
New Patient Pain/Controlled Substances Medical History
If you are suffering with addiction or chronic pain, please fill out our New Patient Pain Medication and/or Addiction Medical History form. This will help save time during your first appointment and ensure we're able to start addressing your concerns quickly and accurately.
Free Screening
Free Screening
Free screening form links.
Free CIRS Screening
Complete the Free CIRS Screening Test to evaluate your risk factor for Chronic Inflammatory Response Syndrome. This test should be completed prior to your first appointment if you believe you are suffering from CIRS or mold/biotoxin related illness.
Free Lyme Screening
Take our Free Lyme Disease Screening Test to evaluate your risk of tick-borne illness.
Miscellaneous
Miscellaneous Patient Forms
Misc forms to be used for information regarding a number of different concerns.
Visual Contrast Sensitivity (VCS)
CIRS Patients Only: Prior to your first appointment, please complete the Visual Contrast Sensitivity test and bring the results with you for your first appointment. The cost of this test is $10, it can be completed in about 10 minutes, and you will receive your results immediately. This test has a 95% accuracy in predicting CIRS.
New Patient À la carte
For patients interested in IV therapy and nutritional therapies, please fill out our À la carte New Patient Form before your first visit to our offices.
Followup À la carte
Before each visit to our office for IV and/or nutritonal services, please fill out our À la carte Established Patient Form before your first visit to our offices.
Medical Symptoms Questionnaire
Complete our Medical Symptoms Questionnaire to provide a comprehensive description of past and present symptoms, their severity, and progression throughout treatment. Note: Only fill out this form if requested by your doctor.
Daily Symptom Log
Daily Symptom Log availability
Some patients who don't like trying to figure out what their symptoms have been like between patients may prefer to have a daily symptom log that they can fill out at their convenience during the interval between visits.
For folks with this preference, we've created daily symptom logs that can be used to more accurately track their symptoms. These symptom logs can be downloaded and completed daily or every few days at your convenience. To use this free tool, simply download the appropriate spreadsheet to your computer, share it with nurse1@appwell.net so it can be updated to your chart.
The following free symptom tracking logs are available:
- Symptom Tracker Meds for patients using controlled medications.
- Symptom Tracker CIRS & Controlled Meds for Chronic Inflammatory Response Syndrome patients using controlled medications.
- Symptom Tracker CIRS (Controlled Inflammatory Response Syndrome).
- Symptom Tracker MSIDS/Lyme/Tick-Borne Illness for those being followed for these illnesses.
Est. Patients
Established Patient Forms
These forms are to be used for established patients to ensure accurate tracking of improvements and any new symptoms that may present.
Patient Satisfaction Survey
We are constantly working to improve the quality of our services. Please take our Patient Satisfaction Survey to share feedback relating to your experience with our staff and our office.
Follow-Up CIRS History Form
CIRS patients only: Please complete the CIRS History Follow-Up before each follow-up visit so we're able to assess the improvement of your condition and the benefit of your current treatment protocol.
Follow-Up Combined CIRS/Controlled Substances
If you are a current patient receiving care for Chronic Inflammatory Response Syndrome (CIRS), Chronic Pain, or Substance Abuse please fill out our Follow-Up Combined CIRS, Pain and/or Addiction Form prior to every visit. This ensures we understand the progress of your treatment.
Follow-Up Controlled Substances/Chronic Pain
If you're receiving treatment for a combination of Substance Abuse or Chronic Pain we ask that you fill out the Follow-Up Combined Medical History Form prior to each visit. This allows us to quickly and accurately assess your progress and adjust therapies as required.