PATIENT PRE-REGISTRATION Please fill out the form below and submit for pre-registration. Last Name(required) First Name(required) Middle Name Phone Email(required) Date of Birth – MM/DD/YYYY(required) Gender(required) Race / Ethnicity Weight(required) Height(required) Height(required) Check All That Apply (required) Currently Under A Doctors Care Do you consider yourself healthy? Acid Reflux Afternoon Headaches Anxiety Attention Difficulties Asthma Bleeding Disorder "Brain Fog" or "Mental Clouding" Cardiovascular Problem(s) Chest Pain or Discomfort Chronic Pain Concussion Constipation Consume Alcohol Depression Diabetes Diarrhea Difficulty Controlling Blood Glucose Difficulty Controlling Blood Pressure Difficulty Standing Still Dizziness Upon Standing Ear / Sinus Problem(s) E.D.S. (Ehlers-Danlos Syndrome) Estrogen Imbalance Evening Edema Excercise Intolerance Excessive Sweating Exhaustion Fainting Fatigue Gastro-Intestinal Problem(s) Headaches Heartburn Heart Disease Heart Palpitations Heat Intolerance "Hot Flashes" Kidney Disease Learning Disorder(s) Light-Headedness Little or No Energy Memory Difficulties Menstruating Menopause / Perimenopause Migraine Headaches Muscular Problem(s) Nausea "Night Sweats" Occasional Light-Headedness Other Psychological / Psychiatric Diagnosis Persistently Cold Hands or Feet P.O.T.S. (Postural Orthostatic Tachycardia Syndrome) Restless Legs Sex Dyfunction Shortness of Breath Sleep Difficulties Seizure Disorder(s) Sickle Cell Skeletal Problem(s) Sleep Disorder(s) Smoker Stroke Thyroid Dysfunction Traumatic Injury Trouble Falling Asleep Unexplained Arrhythmia Unexplained Seizure Upset Stomach Varicose / Spider Veins Surgery – Please Describe Additional Conditon / Diagnosis / Issue – Please Describe Excercise – Please Describe Activity & Frequency Sleep – Please Describe Sleep Habits & Patterns Allergies – Please Describe Additional Info About Lifestyle / Health / Concerns Submit
