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.
ALERT: Click on the green “Save and Continue Later” button (always present at the bottom right corner of this window) if you do not plan to write for a few minutes. Otherwise, the form will TIME OUT and lose ALL your information.
Also, you must click the “Submit” button at the end of your questionnaire and please send it at least 1 full day prior to your consultation if you possibly can.
If you do not see the “Thank You” page with the flower, please make sure you have filled out correctly all fields. Incorrectly filled fields show red color. Please fill out all fields correctly and submit again.