Physician Referral Please fill in the form below and submit to be matched with a physician for an assessment of your autonomic nervous system. First Name Email Organization (Optional) PHONE Date of Birth Gender Race/ Ethnicity Weight Height ALL INFORMATION PROVIDED WILL REMAIN CONFIDENTIAL AND WILL BE USED FOR THE PURPOSES OF PHYSICIAN REFERRAL FOR AN ANS EVALUATION. Please Check All That Apply Currently under a doctor's care Do you consider yourself healthy? Acid Reflux Afternoon Headaches Alcohol Consumption Anxiety Attention Difficulties Asthma Bleeding Disorder "Brain Fog" or "Mental Clouding" Cardiovascular Problem(s) Chest Pain or Discomfort Chronic Pain Concussion Constipation Depression Diabetes Diarrhea Difficulty Controlling Blood Glucose Difficulty Controlling Blood Pressure Difficulty Standing Still Dizziness Upon Standing Ear / Sinus Problem(s) EDSh (Ehlers-Danlos Syndrome/Hypermobility) Estrogen Imbalance Evening Edema Excercise Intolerance Excessive Sweating Exhaustion Fainting Fatigue Gastrointestinal Problem(s) Headaches Heartburn Heart Disease Please Check All That Apply Heart Palpitations Heat Intolerance "Hot Flashes" Kidney Disease Learning Disorder(s) Light-Headedness Little or No Energy Memory Difficulties Menstrual Difficulties Menopause / Perimenopause Migraine Headaches Muscular Problem(s) Nausea "Night Sweats" Occasional Light-Headedness Other Psychological / Psychiatric Diagnosis Persistently Cold Hands or Feet POTS (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 Allergies – Please Describe Additional Conditon / Diagnosis / Issue – Please Describe Excercise – Please Describe Activity & Frequency Sleep – Please Describe Sleep Habits & Patterns Additional Info About Lifestyle / Health / Concerns Submit
