Before Your First Appointment

Please fill out and submit all new patient forms at least 24 hours before your appointment.
You can fill out your new patient forms using the form below on this page. If you need to take a break or come back to complete the form later, you can scroll to the bottom to save it and continue where you left off. If you prefer to complete the forms by hand, you can download the physical forms here, then email them to info@corehealthstl.com when you are finished.
If you have any recent labs (within 12 months), please email them to us prior to your appointment to info@corehealthstl.com.
Please arrive on time.
We have a 48-hour cancellation policy.

Note: If these steps are not followed, it may compromise the full value of your consultation and therefore, we will kindly reschedule your appointment.

We look forward to helping you in your health journey!

Please fill out the new patient paperwork below.

This form consists of 10 sections including: Personal History, Health Assessment, Initial Consultation, Current Medications, Medication History, Dental history, Social History, Family History, Metabolic Assessment, and HIPAA form.

Step 1 of 25

Health Assessment
On a scale of 1-10 (1 being poor, 10 being amazing), please rate your health and life in the following categories:
Energy*
Mental Capacity*
Diet*
Sleep*
Fitness*
Relationships*
Peace (opposite of stress)*

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Medications, Supplements & Hospitalizations
Click the + to add more lines.
Please list all current medications:*
Medication Dose Frequency Start Date Reason
Please list all past medications:*
Medication Dose Frequency Start Date Reason
Please list supplements you are currently taking:*
Medication Dose Frequency Start Date Reason
Please list any hospitalizations:*
Date Reason

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Family History
In the blanks below under each condition, please note if anyone in your family has ever had these conditions (Father, Mother, Grandmother(s), Grandfather(s), Spouse, or Child).
Family History Conditions*
Allergy ADHD Anxiety Asthma Autism
*
Bed Wetting Cancer Colic Celiac Constipation
*
Depression Diabetes Dementia Bipolar Ear Infections
*
Epilepsy Eczema Headaches Heartburn High Blood Pressure
*
IBS Environmental Sensitivities Indigestion Infertility Insomnia
*
Heart Disease Autoimmune Disease Obesity Food Allergies Back Problems Sinus Trouble

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Metabolic Assessment
Please mark the appropriate number 0-3 on all questions. 0 being least/never and 3 being most/always.
Category 1
Feeling that bowels do not empty completely*
Lower abdominal pain relief by passing gas or stool*
Alternating constipation and diarrhea*
Diarrhea*
Constipation*
Hard, dry, or small stool*
Coated tongue of "fuzzy" debris on tongue*
Pass large amount of foul smelling gas*
More than 3 bowel movements daily*
Use laxatives frequently*

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Category 2
Excessive belching, burping, or bloating*
Gas immediately following a meal*
Offensive breath*
Difficult bowel movements*
Sense of fullness during and after meals*
Difficulty digesting fruits and vegetables*
Undigested foods found in stools*

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Category 3
Stomach pain, burning, or aching 1-4 hours after eating*
Do you frequently use antacids?*
Feeling hungry an hour or two after eating*
Heartburn when lying down or bending forward*
Temporary relief from antacids, food, milk, carbonated beverages*
Digestive problems subside with rest and relaxation*
Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine*

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Category 4
Roughage and fiber cause constipation*
Indigestion and fullness last 2-4 hours after eating*
Pain, tenderness, soreness on left side under rib cage*
Excessive passage of gas*
Nausea and/or vomiting*
Stool undigested, foul smelling, mucous-like, greasy, or poorly formed*
Frequent urination*
Increased thirst and appetite*
Difficulty losing weight*

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Category 5
Greasy or high fat foods cause distress*
Lower bowel gas and/or bloating several hours after eating*
Bitter metallic taste in mouth, especially in the morning*
Stool color alternates from clay colored to normal brown*
Reddened skin, especially palms*
Dry or flaky skin and/or hair*
History of gallbladder attacks or stones*
Have you had your gallbladder removed*

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Category 6
Crave sweets during the day*
Irritable if meals are missing*
Depend on coffee to get yourself going or started*
Get lightheaded if meals are missing*
Eating relieves fatigue*
Feel shaky, jittery, tremors*
Agitated, easily upset, nervous*
Poor memory, forgetful*
Blurred vision*

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Category 7
Fatigue after meals*
Crave sweets during the day*
Eating sweets does not relieve cravings for sugar*
Must have sweets after meals*
Waist girth is equal or larger than hip girth*
Frequent urination*
Increased thirst & appetite*
Difficulty in losing weight*

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Category 8
Cannot stay asleep*
Crave salt*
Slow starter in the morning*
Afternoon fatigue*
Dizziness when standing up quickly*
Afternoon headaches*
Headaches with exertion or stress*
Weak nails*

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Category 9
Cannot fall asleep*
Perspire easily*
Under high amounts of stress*
Weight gain under stress*
Wake up tired after 6 or more hours of sleep*
Excessive perspiration with little or no activity*

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Category 10
Tired, sluggish*
Feel cold- hands, feet, all over*
Require excessive amounts of sleep to function properly*
Increase in weight gain even with low- calorie diet*
Difficult infrequent bowel movements*
Depression, lack of motivation*
Morning headaches that wear off as the day progresses*
Outer third of eyebrow thins*
Thinning of hair on scalp, face, or genitals or excessive falling of hair*
Dryness of skin and scalp*
Mental sluggishness*

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Category 11
Heart palpitations*
Inward trimbling*
Increased pulse even at rest*
Nervous and emotional*
Insomnia*
Night sweats*
Difficulty gaining weight*

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Category 12
Diminished sex drive*
Menstrual disorders or lack of menstruation*
Increased ability to eat sugars without symptoms*

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Category 13
Increased sex drive*
Tolerance to sugars reduced*
"Splitting" type headaches*

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Category 14
Urination difficulty or dribbling*
Urination frequent*
Pain inside of legs or heels*
Feeling incomplete bowel excavation*
Leg nervousness at night*

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Category 15
Decrease in libido*
Decrease in spontaneous morning erections*
Decrease in fullness of erections*
Difficulty in maintaining morning erections*
Spells of mental fatigue*
Inability to concentrate*
Episodes of depression*
Muscle soreness*
Decrease in physical stamina*
Unexplained weight gain*
Increase in fat distribution around chest and thighs*
Sweating attacks*
More emotional than in the past*

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Category 16
Are you perimenopausal*
Alternating menstrual cycle lengths*
Extended menstrual cycle, greater than 32 days*
Shortened menses, less than every 24 days*
Pain and cramping during periods*
Scanty blood flow*
Heavy blood flow*
Breast pain and swelling during menses*
Pelvic pain during menses*
Irritable and depressed during menses*
Acne break out*
Facial hair growth*
Hair loss/thinning*

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Category 17
How many years have you been in menopausal*
Since menopause, do you ever have uterine bleeding?*
Hot flashes*
Mental fogginess*
Disinterest in sex*
Mood swings*
Depression*
Painful intercourse*
Shrinking breast*
Facial Hair Growth*
Acne*
Increased vaginal pain, dryness or itching*

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HIPAA Form
Core Health, 1034 S. Brentwood Blvd, Ste 1450 , Richmond Heights, MO 63117, Notice of Privacy Practices This notice describes how health information about you may be used and disclosed and how you can get access to this information. It is effective April 14, 2003, and applies to all protected health information contained in your health records maintained by us. We have the following duties regarding the maintenance, use and disclosure of your health records: (1) We are required by law to maintain the privacy of the protected health information in your records and to provide you with this Notice of our legal duties and privacy practices with respect to that information. (2) We are required to abide by the terms of this Notice currently in effect. (3) We reserve the right to change the terms of this Notice at any time, making the new provisions effective for all health information and records that we have and continue to maintain. All changes in this Notice will be prominently displayed and available at our office. There are a number of situations in which we may use or disclose to other persons or entities your confidential health information. Certain uses and disclosures will require you to sign an acknowledgement that you received this Notice of Privacy Practices. These include treatment, payment, and health care operations. Any use or disclosure of your protected health information required for anything other than treatment, payment or health care operations requires you to sign an Authorization. Certain disclosures that are required by law, or under emergency circumstances, may be made without your Acknowledgement or Authorization. Under any circumstance, we will use or disclose only the minimum amount of information necessary from your medical records to accomplish the intended purpose of the disclosure. We will attempt in good faith to obtain your signed Acknowledgement that you received this Notice to use and disclose your confidential medical information for the following purposes. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office once you have provided Consent. Treatment: We will use your health information to make decisions about the provision, coordination or management of your healthcare, including analyzing or diagnosing your condition and determining the appropriate treatment for that condition. It may also be necessary to share your health information with another health care provider whom we need to consult with respect to your care. These are only examples of uses and disclosures of medical information for treatment purposes that may or may not be necessary in your case. Payment: We may need to use or disclose information in your health record to obtain reimbursement from you, from your health-insurance carrier, or from another insurer for our services rendered to you. This may include determinations of eligibility or coverage under the appropriate health plan, pre-certification and pre-authorization of services or review of services for the purpose of reimbursement. This information may also be used for billing, claims management and collection purposes, and related healthcare data processing through our system. Operations: Your health records may be used in our business planning and development operations, including improvements in our methods of operation, and general administrative functions. We may also use the information in our overall compliance planning, healthcare review activities, and arranging for legal and auditing functions. There are certain circumstances under which we may use or disclose your health information without first obtaining your Acknowledgement or Authorization. Those circumstances generally involve public health and oversight activities, law-enforcement activities, judicial and administrative proceedings, and in the event of death. Specifically, we may be required to report to certain agencies information concerning certain communicable diseases, sexually transmitted diseases or HIV/AIDS status. We may also be required to report instances of suspected or documented abuse, neglect or domestic violence. We are required to report to appropriate agencies and law-enforcement officials information that you or another person is in immediate threat of danger to health or safety as a result of violent activity. We must also provide health information when ordered by a court of law to do so. We may contact you from time to time to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. You should be aware that we utilize an “open adjusting room” in which several people may be adjusted at the same time and in close proximity. We will try to speak quietly to you in a manner reasonably calculated to avoid disclosing your health information to others; however, complete privacy may not be possible in this setting. If you would prefer to be adjusted in a private room, please let us know and we will do our best to accommodate your wishes. Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your healthcare. Communication Barriers and Emergencies: We may use and disclose your protected health information if we attempt to obtain consent from you but are unable to do so because of substantial communication barriers and we determine, using professional judgment, that you intend to consent to use or disclosure under the circumstances. We may use or disclose your protected health information in an emergency treatment situation. If this happens, we will try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If we are required by law or as a matter of necessity to treat you, and we have attempted to obtain your consent but have been unable to obtain your consent, we may still use or disclose your protected health information to treat you. Except as indicated above, your health information will not be used or disclosed to any other person or entity without your specific Authorization, which may be revoked at any time. In particular, except to the extent disclosure has been made to governmental entities required by law to maintain the confidentiality of the information, information will not be further disclosed to any other person or entity with respect to information concerning mental-health treatment, drug and alcohol abuse, HIV/AIDS or sexually transmitted diseases that may be contained in your health records. We likewise will not disclose your health-record information to an employer for purposes of making employment decisions, to a liability insurer or attorney as a result of injuries sustained in an automobile accident, or to educational authorities, without your written authorization. You have certain rights regarding your health record information, as follows: (1) You may request that we restrict the uses and disclosures of your health record information for treatment, payment and operations, or restrictions involving your care or payment related to that care. We are not required to agree to the restriction; however, if we agree, we will comply with it, except with regard to emergencies, disclosure of the information to you, or if we are otherwise required by law to make a full disclosure without restriction. (2) You have a right to request receipt of confidential communications of your medical information by an alternative means or at an alternative location. If you require such an accommodation, you may be charged a fee for the accommodation and will be required to specify the alternative address or method of contact and how payment will be handled. (3) You have the right to inspect, copy and request amendments to you health records. Access to your health records will not include psychotherapy notes contained in them, or information compiled in anticipation of or for use in a civil, criminal or administrative action or proceeding to which your access is restricted by law. We will charge a reasonable fee for providing a copy of your health records, or a summary of those records, at your request, which includes the cost of copying, postage, and preparation or an explanation or summary of the information. (4) All requests for inspection, copying and/or amending information in your health records, and all requests related to your rights under this Notice, must be made in writing and addressed to the Privacy Officer at our address. We will respond to your request in a timely fashion. (5) You have a limited right to receive an accounting of all disclosures we make to other persons or entities of your health information except for disclosures required for treatment, payment and healthcare operations, disclosures that require an Authorization, disclosure incidental to another permissible use or disclosure, and otherwise as allowed by law. We will not charge you for the first accounting in any twelve-month period; however, we will charge you a reasonable fee for each subsequent request for an accounting within the same twelve-month period. (6) If this notice was initially provided to you electronically, you have the right to obtain a paper copy of this notice and to take one home with you if you wish. You may file a written complaint to us or to the Secretary of Health and Human Services if you believe that your privacy rights with respect to confidential information in your health records have been violated. All complaints must be in writing and must be addressed to the Privacy Officer (in the case of complaints to us) or to the person designated by the U.S. Department of Health and Human Services if we cannot resolve your concerns. You will not be retaliated against for filing such a complaint. More information is available about complaints at the government’s web site, http://www.hhs.gov/ocr/hipaa.
Patient Signature*
Date*
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Core Health Staff Signature & Date: ______________________________________________________________________________
Name
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Before Your First Appointment

We're excited that you've made your first appointment and you're taking the steps to creating a healthier life! We can't wait to meet you!

Please fill out the new patient paperwork below.

Step 1 of 25

Personal History

Health Assessment

Initial Consultation

Medications, Supplements & Hospitalizations

Medication History

Dental History

Social History

Family History

Metabolic Assessment

Category 1

Category 2

Category 3

Category 4

Category 5

Category 6

Category 7

Category 8

Category 9

Category 10

Category 11

Category 12

Category 13

Category 14

Category 15

Category 16

Category 17

HIPAA Form

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Medication	Dose	Frequency	Start Date	Reason

Medication	Dose	Frequency	Start Date	Reason

Medication	Dose	Frequency	Start Date	Reason

Date	Reason