New Patient Intake Form

Thank you for filling out this form. We will use this data during our first visit.

Name *
Name
Best Phone to Reach You? *
Best Phone to Reach You?
May We Text You at This Number? *
Date of Birth *
Date of Birth
Genetic Background
check all that apply
Please list any first degree relatives and their corresponding medical conditions.
Date of First Symptoms
Date of First Symptoms
Date of Official Diagnosis
Date of Official Diagnosis
i.e. fatigue, bladder, pain, weakness, tingling, vision problems etc.
When was your last relapse, if any?
When was your last relapse, if any?
Please start with oldest medication and work your way to current medication.
Do you smoke cigarettes (tobacco)?
Were you breast-fed as an infant?
Please list dosages as well if you know.
Readiness Assessment
Readiness Assessment
I am ready to change my diet in order to improve my health.
I am ready to exercise more to improve my health.
I am ready to implement stress-management techniques.
I need to improve my social and support network.
I am open to the idea of pharmaceuticals to help treat my MS.
We look forward to seeing you soon! Please keep me on the mailing list.