Your Name (required)

Your Email (required)

Date of Birth (required)

Age (required)

Gender
MaleFemale

Parent or Guardian

Telephone Number (required)

Work Number

Your Address (required)

Emergency Contact

Occupation

Marital Status
YesNo

How did you hear about the Dubin Clinic?

Who were you referred by?

Primary reason for seeking treatment? (required)

How long have you suffered with this problem? (required)

Any other complaints or additional reasons for seeking treatment?

Is there a family history of your problems?
YesNo

Select any of the following that apply to you or members of your family: (Choose all that apply)
Thyroid DiseaseKidney DiseaseAsthmaNeurological DiseaseInfectious DiseaseDiabetesCancerGastrointestinal DiseaseProstate ProblemsGlaucomaEpilepsyOther

Do you have a history of: (Choose all that apply)
Traumatic brain injurySeizuresMigrainesInsomniaEating problemsHormonal issuesChronic painChronic fatigueFibromyalgiaChronic Lyme’s diagnosis

Identify other chronic illnesses you may have:

Would you like improvement with any of the following? (Choose all that apply)
Digestion - Reflux, Gas, ConstipationSleep - Falling asleep or staying asleepSense of Well BeingEnergy

Do you use any of the following substances? (Choose all that apply)
CaffeineTobaccoAlcoholIllicit Drugs

If so, provide us with the type, amount, frequency and how long you have been taking the substances?

Do you get regular physical exercise? If so, what type and frequency?

Do you practice relaxation or meditation? If so, what type and frequency?

Current Medications:
(Please list any medications that you are now taking. Include non-prescription medications & vitamins or supplements. Also include strength & number of pills per day and how long you have been taking the medication)

What have you tried doing to resolve your main health complaint(s) that Did Not work?

Have you become discouraged or stressed about handling this problem?

When your problem is at its worst, how does it make you feel?

How does this problem interfere with the following areas in your life (Work, Family, Hobbies & Life)?

When it’s at it’s worst, how much older does this make you feel?

Do you know how this problem may have started?

What effect does this have on your body functions?

Are you here visiting us to:
Resolve my immediate problemLifestyle program for optimized livingBothOther

How have you taken care of your health in the past? (Choose all that apply)
MedicationsRoutine MedicalExerciseDiet & NutritionHolisticVitaminsChiropracticOther

How did the previous methods work for you?

What are you afraid this might be or will be affecting without change? (Choose all that apply)
JobKidsMarriageSleepFreedomFuture abilitiesFinancesTime

Are there any health conditions you are afraid this might turn into? (Choose all that apply)
Diminished future abilitiesStressWeight gainHeart diseaseDepressionSurgeryArthritisCancerDiabetesOther

Where do you picture yourself being in the next 3-5 years if this problem is not taken care of? (Please be specific)

What would be different or better without this problem? (Choose all that apply)
Diminished stressMore energySelf esteemConfidenceSleepWorkOutlookFamily

If we were to sit down and discuss your life 3 years from now and look back at today, what would have to have happened for you to be happy with your progress?

What potential barriers do you foresee that would prevent these things from happening?

Do you feel it is possible to eliminate or prevent these potential barriers?

What are your strengths that will enable you to accomplish your goals?

Rate on a scale of 1-10: How important is it for you to resolve your health concerns?

Rate on a scale of 1-10: Do you feel that you are coachable and would enjoy a mentor in helping you?

Rate on a scale of 1-10: Are you prepared to make the appropriate lifestyle changes that may be necessary in order to achieve your goals?

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