About This Form

  1. This form was designed to be filled out on-line in your web browser. The fields are areas for you to type in your information. Use the tab key to move to the next field. The shaded areas labeled with “Select” indicate drop-down menus for you to select the most relevant option. The check boxes are also shaded; please check any and all of the choices that apply to your state of health.
  2. After you are finished filling out this form, please print, initial each page in the bottom right corner, sign and date it, and bring it with you to your first appointment.
  3. Saving your input data: due to privacy issues, this form does not auto-save. The only way to save your input data is to save this page as a HTML file with Firefox, all other browsers tested DO NOT save the input data. Saving the input data is only needed in cases where you want a digital backup copy or to work off-line. Furthermore, because this form does not auto-save your information please be aware that leaving this page before printing the form or saving with Firefox will result in the complete loss of all data.
  4. This form functions best in Firefox, Chrome, Opera, and poorest in older versions of IE. Also, you must have JavaScript enabled in your browser for certain features of this form to function properly.