I look forward to chatting with you! Please fill out the information below prior to our appointment. Answer the questions to the best of your ability.


Name *
What do you want to talk about during our session?
Include any recent or past diagnoses for yourself, any lab values that have been outside the range of normal etc.
Please name each along with dose
List your breakfast, lunch, dinner, snacks and anything else you'd normally eat or drink in a day.
(1 drink = 4 ounces of wine, 1.5 ounces of liquor, 12 ounces of beer)