New Patient Intake Form

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Please do your best and carefully consider each of the following questions.  Your accurate answers will help to identify underlying causes of illness and will also assist the doctor to formulate the best plan of action. Please complete at least 24 hours prior to first visit. This will allow Dr. Galina the chance to review your case and prepare for your visit.


Please be advised that you are providing information on an encrypted form that has a third party verification for standards (TRUSTe) . If this is a concern for you or if you are unable to complete this form online, please contact Dr. Galina for a PDF version. 


Thank you,

Dr. Galina Mironova


General Information




MM/DD/YYYY







Address





Contact Information


123-456-7890

123-456-7890


Emergency Contact



123-456-7890





123-456-7890





Personal Health History







General



Energy and Stress




Family History

For each of the family members listed below please list age and health status (any diseases, etc.); if deceased please list age at death and cause of death.  Please put 'N/A' if family member is not applicable to you.










Childhood History




Lifestyle




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