Health History Intake Form

*We ask for your e-mail because it is often the easiest way to communicate with our patients. BCA does NOT share this info with ANYONE. If you do not wish to receive our e-newsletter, please let us know. We are committed to respecting your privacy.

Hospitalizations / Surgeries

X-Rays / CT Scans / MRIs / Special Studies

Review of Systems & Symptoms

Sleep

Diet / Lifestyle

What is a typical day in the life of your diet

To Our Valued Patients:  In order to stay open and safe, we are requiring patients to be vaccinated.  Please contact Lindsey if you are unvaccinated for a medical reason, disability, or religious exemption and we will make arrangements.  Bring your vaccine card with you!  Treatments are only in private rooms.