louisa williams, ND

TREATING THE ROOT CAUSE OF DISEASE

NEW PATIENT FORM
Marital Status
SURGERIES

Include your age at the time and all operations, even moles, etc. removed and circumcision. 

SERIOUS INFECTIONS AND DISEASES

Pneumonia, mono, tuberculosis., cancer, heart attack, chronic bronchitis, colitis, mumps, measles, chicken pox, etc. If it was more than one year, please indicate the age range. For example: Age 26-30. Treated for cancer.

TOXIC PROFESSIONS OR EXPOSURES PAST OR PRESENT

Artist, graphic designer, dentist, dental assistant, gas station worker, painter, industry, computer cleaning, etc. If it was more than one year, please indicate the age range. For example: Age 26-30. Worked as a car mechanic.

FEMALE REPRODUCTION

Pregnancies/ births/ abortions/ IUDs/ episiotomy / fibroids / cysts, etc.

DRUGS AND MEDICATIONS
Were any of these items part of your life in the past?
Are any of these items part of your life today?

Please list prescriptions, street drugs, and the amount of alcohol, and cigarettes you've used in the past and present. If it was more than one year, please indicate the age range. For example: Age 26-30. Smoked a pack of cigarettes a day.

INJURIES AND ACCIDENTS
MAJOR PSYCHOLOGICAL TRAUMA
LONG VISITS OR LIVED IN A FOREIGN COUNTRY
Treated for parasites or infections?
KNOWN ALLERGIES
DENTAL INTERVENTIONS

Please indicate whether there have been root canals, implants (titanium or zirconium?), extractions, cavities filled, crowns, a bridge or any other dental intervention on each tooth. Please refer to this dental chart and note that the wisdom teeth are numbers 1, 16, 17 and 32. Please indicate what materials were used in any cavities listed. Also, include the age of first silver amalgam fillings, braces, retainers, or night guards, etc. If you have recent dental x-rays, please upload them below above the "submit" box.

CHIEF HEALTH COMPLAINTS

Write your chief complaint(s) below and rate the approximate age of onset. Also indicate the severity: "0" corresponds to no symptoms, and "10" corresponds to the most severely-felt symptoms.

Where do you have pain or dysfunction?

Please read and follow these instructions for requested lab work or if you have recent blood tests upload them below. Recent dental x-rays may be uploaded below as well. These documents can also be emailed.

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