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