Adult New Patient Form Part 5

Adult New Patient FMI Part 5

  • SYMPTOM REVIEW
    Rate each of the following symptoms based upon your typical health profile for the past 14 days.
    Point Scale: 0 – Never or almost never have the symptom, 1 – Occasionally have it, 2 – Occasionally have it, effect is severe, 3 – Frequently have it, effect is not severe 4 – Frequently have it, effect is severe,
  • HEAD
  • HEART
  • EYES
  • (Does not include near or far-sightedness)
  • LUNGS
  • EARS
  • DIGESTIVE
  • NOSE
  • JOINTS/MUSCLE
  • MOUTH/THROAT
  • WEIGHT
  • SKIN
  • ENERGY/ACTIVITY
  • MIND
  • EMOTIONS
  • OTHER
  • READINESS ASSESSMENT
    Rate on a scale of: 5 (very willing) to 1 (not willing).

    In order to improve your health, how willing are you to:
  • Rate on a sale of : 5 (very confident) to 1 (not confident at all)
  • Rate on a sale of : 5 (very supportive) to 1 (very unsupportive)
  • Rate on a scale of: 5 (very frequent contact) to 1 (very infrequent contact))
  • This is the last form of 5