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Personal Health History Questionnaire

Personal Health History Questionnaire

* This document has been secured with a HIPAA-compliant asymmetric encryption algorithm to guarantee the confidentiality of your health information.

Filling out this form as completely and thoroughly as possible will ensure that your consultation with Dr. Lonsdorf will be efficient and beneficial. This usually takes about 20-30 minutes. Please have your health information, medications and supplements handy when you sit down to fill it out.

Please complete it at least 3 full days prior to your consultation, so we can enter the information into your electronic health record and Dr. Lonsdorf has time to review it ahead of your session.

Thank you!

*Please do not use Firefox web browser as you will not be able to SAVE if you need to.*

Personal Health History Questionnaire

We would love to hear from you! Please fill out this form and we will get in touch with you shortly. Make sure you see the "Thank You" - page after submitting the form. If you don't check that you have filled out all required fields.

Step 1 of 9

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  • This field is for validation purposes and should be left unchanged.
  • NOTE! YOU MUST WRITE CONTINUOSLY TO THE END or this form may time out and you will lose all your information.

    IF YOU MUST STOP FOR A FEW MINUTES….

    CLICK ON THE GREEN SAVE AND CONTINUE LATER button (always present at the bottom right corner of this window). A popup will ask you to enter your email address, and it will then email you a link you can click on when you are ready to continue. Otherwise you will LOSE all you have entered as this form times out (we have no control over that, unfortunately.)

  • Section 1: Select Consultation Type

  • Section 2: Contact Information and Vital Statistics

    (Please note that this practice does not accept Medicare or Medicaid and most insurance companies do not cover phone or Skype consultations.)
  • Emergency Contact

  • (###) ###-####
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  • Vital Statistics

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  • COVID-19 Vaccination

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  • Section 3: Wellness Issues, Medications and Supplements

    Please list any health conditions you have in order of severity. (You may enter up to 4 wellness issues.)
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  • Past Health History

  • Prescription Drugs

  • Supplements

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  • Section 4: Lifestyle & Health History Questionnaire

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
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  • Environmental Health

  • Toxin Exposure and Sensitivity

  • Women's Health

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  • Section 5: Please describe what you hope to achieve from your consultation.




  • If you are having a phone or Zoom consultation, please fill out sections 6, 7 and 8. If you are coming for an office visit, it is recommended but not required that you fill out sections 6 and 7, and you may skip to Section 8 if you wish."

  • Section 6: AMA Questionnaire

  • Section 8: Your Dosha Balance (for Women)

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  • Section 7: Your Dosha Balance (for Men)

  • Section 8: Informed Consent Agreement


  • 1. Program Nature and Participation


  • 2. Complementary Nature of Services


  • 3. Wellness or Ayurveda-Only Consultations


  • 4. Medical Treatment Modifications


  • 5. Disclosure of Health Information


  • 6. Responsibility for Advice


  • 7. Nature of Herbal and Wellness Recommendations


  • 8. FDA Statement


  • 9. Individual Reactions and Assumption of Risk


  • 10. Privacy Policy


  • 11. AI Support Tool


  • 12. Telemedicine Consent


  • 13. Paper Records Policy


  • 14. Secure Email Messaging


  • 15. Fees and Billing Policies

    I agree to pay at the time of booking or time of service, as described in the Fee Schedule, all fees that I incur, or which are incurred on my behalf. I understand that such fees may change without notice; however, any agreed-upon package or program that I have started will be honored through its duration as stated in the materials I received. I have read the current fee schedule provided to me and agree to all terms, including cancellation and refund policies, overtime fees, and fees for email responses beyond those included in the program.

    Billing for Additional Minutes:
    I understand and agree to pay the hourly rate, as quoted in my confirmation email, for any additional consultation minutes that accrue beyond the time originally scheduled and already paid for, for my one-time visit or, if part of a consultation package, the actual consultation time in addition to that allotted for as described in the flyer I received.

    I understand I will be informed by email after the consultation regarding the total of any additional minutes and the amount of any additional charge to my credit card, which I hereby authorize to be charged automatically.

    Billing for Doctor Services Outside of the 2-Week “After” Window:
    Included in your consultation or package fee are all responses to questions you send us in the 2-week period after you receive your visit recommendations. After 2 weeks, short answers that take the doctor less than 5 minutes to answer and do not require her to research into your medical chart materials are also included.


  • 16. 72-Hour Cancellation Notice Requirement


  • 17. Refund Policy


  • 18. Medicare Non-Acceptance


  • 19. Limitation of Liability


  • 20. Zoom Communications


  • 21. Legal and Litigation Limitation


  • 22. Open Payments Disclosure


  • Final Notice

    This agreement is intended to have legal significance.

  • NOTE: Click the “Submit” button below to submit it.

    AFTER SUBMITTING, if you see the Thank You page with the lotus flower, your form will be encrypted and saved and the doctor can access it.

    If after submitting you remain on this page, then be sure to scroll up and complete the required questions you may have missed. These will be highlighted in red.

    IF YOU HAVE PROBLEMS, PLEASE CONTACT US AT 641-469-3174.

  • Clear Signature
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Nancy K. Lonsdorf, MD
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