Forms

New Patient Form

If you are a new patient at Be Well, there is some information we need for your consultation and examination. Fill in the online form below and press submit. 
OR if you prefer to fill this out at Be Well please allow 10 minutes before your appointment.
 

New Patient -Online Form

 

Name *
Name
Checkbox
1 = mild, 10 = worst imaginable
1 = mild 10 = worst imaginable
1 = Mild 10 = Worst imaginable
1 = Mild 10 = Worst Imaginable
Please list all medications you presently take, including over the counter.
Please check any of the following you have had in the past six months:
Are you pregnant?
What is your most common sleep position?
Do you use a pillow?
Pillow type?
Please rate your level of stress for this area of potential stress from 1 being low stress to 10 being high stress.
Please rate your level of stress for this area of potential stress from 1 being low stress to 10 being high stress.
Please rate your level of stress for this area of potential stress from 1 being low stress to 10 being high stress.
Please rate your level of stress for this area of potential stress from 1 being low stress to 10 being high stress.
Please rate your level of stress for this area of potential stress from 1 being low stress to 10 being high stress.
Please rate your level of stress for this area of potential stress from 1 being low stress to 10 being high stress.

 

We look forward to meeting you at your appointment.

-Be Well