Forms
- 1 – New Patient Form
- 2 – WFC Privacy Practices
- 3 – Acknowledgment of Receipt of Privacy Practices
- 4 – Insurance / Self-pay Authorization Form
- 5 – Authorization for Verbal Communications Form
- 6 – Patient Rights and Responsibilities
- 7 – Authorization for Release of Records
- 8 – Power of Attorney for Healthcare
- 9 – Pediatric Tylenol Dosing Table
- 10 – Pediatric Ibuprofen Dosing Table
- 11 – WFC Weekend Newborn Lab and Weight Check
Health Coaching Forms:
Program Information
Eating Questionnaire
Emotional Eating Questionnaire
Fitness Activity Inventory
Baseline Diary
Others:
Colposcopy
Colposcopy Patient Instructions
Endometrial Biopsy Information
IUD Insertion Information
Physical Therapy – Massage:
Cupping Therapy Form
Massage Patient Intake Form
Physical therapy – Personal Training
Activity Pyramid – Blank
Activity Pyramid
Personal Training Intake Form
Dr. Ilkevitch / PMR / Integrative Medicine forms:
PM&R Intake Form
Personal Health Inventory (Optional)
Katie Knipfer, PA / Integrative Medicine Intake Forms
Functional Medicine – Female Intake Form
Functional Medicine – Male Intake Form
Well Child Check Forms
M-Chat Form
GAPS form for Middle to Older Adolescents
GAPS form for Younger Adolescents
ASQ-3 for 9 month olds
ASQ-3 for 18 month olds
ASQ-3 for 24 month olds