Patient Sign Up Form

Are you currently receiving chemotherapy or radiation?

If you have received chemotherapy or radiation, has at least 1 month passed?

When was your illness diagnosed?

Have you had any surgery relating to this problem?

Please tell us about any relevant medical history and/or other treatments and therapies you have done (e.g. illness, hospitalization, yoga, meditation, colonic irrigation, IV treatment etc)

In the last 5 years, have you experienced any emotional shock?

If you suffer pain, where is it located?

On a scale of 1 to 10, how bad is the pain (1 being mild, 10 being severe)

If you suffer ascites or edema (fluid retention), where is it located?

How many root canals do you have?

How many teeth extractions have you had?

Is there anything else you would like to add that you think we should be aware of?

Please list all pharmaceutical medicine you are currently using