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New Patient Inquiry Form
Our practice strives to provide the best one-on-one and personalized care tailored to your individual needs. Kindly fill out our questionnaire so that we may learn about you as it relates to our program offerings.
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Email
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Your email
Name
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Your answer
Gender
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Your answer
Date of birth
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Please describe the nature of your health concerns.
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Your answer
How long have these health concerns been active?
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Your answer
Have you become discouraged or distressed by these health problems?
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Your answer
Do your health problems affect your...
(severity on a scale from 0 to 10, with 0 the least and 10 the most)
Work
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Family life
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Recreational activities
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Sexual function
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Relationships with friends
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What factors do you believe have contributed to creating these health issues?
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Your answer
Left untended, where do you anticipate these health problems will take you? How do you imagine your life in 3-5 years if these health issues are not addressed?
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Your answer
What are your goals in working with the Plum Spring Clinic (limited/short-term/resolution of symptoms or more holistic functional goals including lifestyle modifications and wellness)?
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Your answer
How would you rate the importance of resolving your health problems?
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Is there anything else that you would like us to know about you or your health concerns?
Your answer
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