Adult Preliminary Form

Basic Requirements

Thank you for your interest in our clinic and taking the time to complete this form. Please review the four basic practice policies below. If your response to any of these four questions is no, our clinic will likely not be able to meet your needs and we do not recommend that you take the time to complete the remainder of the form. At this time, Dr. Chandra is working with patients who are able to come to the office at least every 4 months for appointments. California patients will have the option of doing a secure video conference or phone appointment after the initial in-person evaluation. Currently, out-of-state patients do not have the option for virtual phone or video conference appointments.

Note for those submitting for multiple family members: If you would like to submit for more than one adult or more than one child using the same email address, please contact our office as our system can only process one adult and one child questionnaire per email address.



Treatment Goals

Readiness Self-Assessment

On a scale of 1 (not willing) to 5 (very willing) to achieve your health goals, how willing are you to:

If the patient does not speak English, you will be required to bring a medical translator to all appointments.


History

Do you have a history of any of the following in the last year?


Have you had any of the following recently (in the last 2 mos.) or in the past (>2mos. ago?) Check all that apply:


Please understand that neither the completion of this brief questionnaire nor the practitioner reviewing it prior to a face-to-face appointment will establish a practitioner-patient relationship. If you have severe or potentially life-threatening physical or emotional situations arise while waiting for an appointment in this practice, you should go to a hospital emergency department or at least immediately communicate with your primary care physician. Please do not contact our offices as we will not be able to provide any advice or care until your first in-person appointment. Thank you.


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