Please complete this questionnaire. It will help Dr. Wilcox provide you with a complete holistic, integrated medical evaluation. Although it is 10 pages, most of it is check boxes. The time you invest will help Dr. Wilcox better understand your health issues and will save you time and money during your consultation.

However, if you have limited time, complete only the first three pages. You may complete the remainder later.

If you have medical records from the past two years, such as test results or imaging reports, email those to us. Dr. Wilcox will review those during your consultation. This will also help avoid repeating tests that have been done recently. Also, if you have done a provoked urine test for toxic metals, email us those reports to us. Dr. Wilcox is the only person who will review this information. This information may only be shared or disclosed as detailed in our Notice of Privacy Practices as required by HIPPA. If you have questions, please ask. If there is anything you wish to bring to our attention that is not asked on this form, please note it in the COMMENTS section at the very end of the form, or email it to us. Copying your completed questionnaire for your own records may be wise.