Complimentary Patient Prescreening

Complimentary Patient Prescreening

Please fill out our Complimentary Patient Prescreening Form below with all your info.
Technology has become such a vital component to the medical field
  • What are your main complaints (In Order of Importance):Duration of Problem: 
  • DrugDosage#Times/DayStart Date 
  • SCALE OF SYMPTOMS SUFFERED DURING THE LAST SIX (6) MONTHS
    Select option 0 If You Do Not Suffer From This AT ALL
    Select option 1 If You Suffer Occasionally (less than twice a week) and It Is Not Severe
    Select option 2 If You Suffer Frequently (2 or more times per week) and It Is Not Severe
    Select option 3 If You Suffer Occasionally (less than twice a week) and When You Do It Is Severe
    Select option 4 If You Suffer Frequently (2 or more times per week) and When You Do It Is Severe
  • CONSTITUTIONAL SYMPTOMS

  • Lungs

  • EMOTIONAL/MENTAL SYMPTOMS

  • EYES

  • GENITOURINARY

  • HEAD/EARS

  • MUSCULOSKELETAL

  • SKIN

  • CARDIOVASCULAR

  • NASAL/SINUS

  • DIGESTIVE

  • MOUTH/THROAT

  • WEIGHT MANAGEMENT

  • This field is for validation purposes and should be left unchanged.