NEW PATIENT FORM
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, excessive 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. Please list vaccination history in that section at the end of this form.
INJURIES AND ACCIDENTS
MAJOR PSYCHOLOGICAL TRAUMA
LONG VISITS OR LIVED IN A FOREIGN COUNTRY Treated or experienced parasites or infections?
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?
VACCINATIONS Please check all that apply:
Please list what you can remember about your vaccination history and adverse reactions you may have had.
I understand that Louisa Williams, a naturopathic doctor, has graduated from a federally-accredited four-year naturopathic medical school, Bastyr University, has taken and passed all phases of the national Naturopathic Physicians Licensing Examination (NPLEX), and has passed state exams in order to be licensed as a naturopathic physician in Vermont. (Texas does not yet license ND’s.)
I further understand that Dr. Williams uses along with the standard exam, history-taking, laboratory tests and appropriate radiographic imaging, energetic testing methods including kinesiology and Matrix Reflex Testing (MRT). Like lab tests, which can also give false negative and false positive results, no energetic testing method is 100% accurate. However, MRT and kinesiology can greatly assist in determining a patient’s diagnosis as well as fine-tuning the most appropriate treatments.
Additionally, I am not associated with any government agency, insurance company, pharmaceutical corporation, or other allopathically-oriented groups aimed at eliminating naturopathic medicine. I am simply here as an individual who wants to feel better.
I have read and understood this document.
S U B M I T