Patient Qualification Intake Form

Patient Qualification Intake Form 2017-02-21T13:53:09+00:00

The Trigenics Treatment Centre Patient Qualification Intake Form

  • The Trigenics Treatment Centre Patient Qualification Intake Form

    Welcome to The Trigenics Treatment Centre. In order to accurately assess you and to determine if you are a true candidate for our care, it is important that you fill out this form as thoroughly as possible. Thank You.
  • Please enter a value between 10 and 99.
  • List In Order Of Importance all OTHER Health Problems/Concerns NOT including Your Main Problem Above.

  • Due To Your Main Problem......

  • On a Scale of 0-10 (10 being unbearable, 0 being No Pain or Discomfort) Please rate the following...

  • Thank You.
    You will be seen shortly with one of our doctors. In the meantime, if there is anything that we can do to make you more comfortable, Please don’t hesitate to ask.

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