Step 1: Male pre-screening  
From Dr. Lor: There are 2 steps to the pre-screening process of becoming a client. All potential clients are asked to answer all questions in full. I will review your responses and make my decision whether you will be moving on to step 2 or not. If the question does not apply to you, please write N/A. 

I do a majority of my communication through email, texting, and video calls. It is expected that you check your emails and text messages to stay in communication with me. If you do not check your emails & text messages nor do you respond back, then my practice may not be a good fit for you. Please consider this before moving forward. 
Today's Date *
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How did you find out about us? *
Full Name *
Best Contact # *
Check all that apply *
Email address *
Complete physical address *
Complete mailing address, if different
Date of Birth *
MM
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DD
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YYYY
Emergency contact person, relationship, and # *
Who do you allow access to your chart so that they may request information or discuss about your health, on your behalf? Please list their full name(s), relationship, DOB, and contact #. *
What are your known allergies (food, medications, or other)? *
Marital Status *
# of children & their ages *
Occupation and if your job/career is stressful. *
Are you looking for Naturopathic recommendations? *
Are you looking for Traditional Chinese Medical recommendations?
Clear selection
Do you have any metal implants or devices implanted in your body? If so, where and since when? *
Who is currently part of your medical team? Please include your practitioner's name &  clinic name *
Major health complaints: Please list in order of significance to you (include when the problem began and precipitating factors) and check which you would like us to focus on today. *
Have you been given a diagnosis for this problem? If so, please describe *
What kind of treatments have you tried and did they work? *
What makes this problem better? *
What makes this problem worst? *
Please describe how these health concerns affect or impair your daily activities? Examples may include your overall quality of life, work, family, hobbies, self-esteem, etc... *
Past medical history: Check  P or C for conditions that you have had in the past or are currently experiencing. Leave those that do not apply blank. *
Past
Current
N/A
Alcohol abuse
Anemia
Arthritis: rheumatoid
Arthritis: osteoarthritis
Arthritis: psoriatic
Blood transfusion
Cancer
Celiac disease
Crohn's disease
Diabetes
Digestive disorder
Epilepsy/seizures
Glaucoma
Heart disease
Heart attack
High blood pressure
High cholesterol
HIV
Hepatitis
Jaundice
Kidney disease
Liver disease
Mental illness
Migraines
Nervous system disorder
Pneumonia
Stroke
Thyroid disorder
Tuberculosis
Varicose veins
Spider veins
What significant trauma (car accidents, sport inujries, falls, etc..) have you had and when? *
Hospitalizations/Surgeries (procedures and dates) *
Tell me everything about your dental health (root canals, infections, extractions, impaction, etc) and which tooth had which problems *
Tell me about all the scars on your body. If no scars, type No scars. *
Cortisone shots and how often *
Please describe briefly your health as a child *
Family Medical History
Alcoholism
Drug abuse
Cancer
Depression/mental illness
Diabetes
Heart disease
Heart attack
Maternal mother
Maternal father
Paternal mother
Paternal father
Biological Sister
Biological brother
Maternal grandma
Maternal grandpa
Paternal grandma
Paternal grandpa
Clear selection
Family Medical History
High blood pressure
Miscarriages
Osteoporosis
Stroke
Other
Maternal mother
Maternal father
Paternal mother
Paternal father
Biological Sister
Biological brother
Maternal grandma
Maternal grandpa
Paternal grandma
Paternal grandpa
Clear selection
Current health and lifestyle: Do you smoke, vape or chew tobacco? *
If yes, how many/much per day? For how long now?
Do you drink alcohol *
If yes, how much per day? For how long now?
Do you exercise? *
If yes, how many times per week? How long are each sessions? Please describe
What is your height? *
What is your weight now? One year ago? Maximum and what year was this? *
Sleep: How would you describe your quality of sleep? Include timing of when you go to bed, # of times your sleep is interrupted, how long it takes you to fall asleep, how long do you stay asleep for and what time do you wake up? Do you feel rested upon wakening? *
Overall, do you feel that your lifestyle contributes to or takes away from your health? *
Nutrition: Please be as detailed as possible. A major area that I always address is nutrition. Please describe your average daily diet for breakfast, lunch, dinner, snacks and food you tend to crave. Include the time when you typically eat each of those meals/snack. Also include your liquids/hydration especially how much daily. *
Please be specific and indicate where you feel pain or discomfort in your body. Describe what it's pattern is like, what it feels like, its intensity etc.. Include your current pain level from 1-10 (10=severe) *
General: Please check any of the following symptoms that you are currently experiencing *
Required
Emotions: Please check any of the following symptoms that you are currently experiencing *
Required
Skin: Please check any of the following symptoms that you are currently experiencing *
Required
Neuro-muscular: Please check any of the following symptoms that you are currently experiencing *
Required
Cardiovascuar: Please check any of the following symptoms that you are currently experiencing *
Required
Respiratory: Please check any of the following symptoms that you are currently experiencing *
Required
Gastrointestinal: Please check any of the following symptoms that you are currently experiencing *
Required
Lymphatic: Please check any of the following symptoms that you are currently experiencing *
Required
Liver/Gall bladder function: Please check any of the following symptoms that you are currently experiencing *
Required
Eyes: Please check any of the following symptoms that you are currently experiencing
Urinary: Please check any of the following symptoms that you are currently experiencing *
Required
Male: Please check any of the following symptoms that you are currently experiencing
Add up the total # of current symptoms you have and write it here *
Additional info you would like for Dr. Lor to know that may have not been listed above:
Medications and Supplements: Write the ones that you are currently taking. Must include full name of product including the manufacturer (unless it is a prescription, then just full name), your dosing, how long you have been taking it and your reason for taking the product. When you have an in office visit, bring all products to your visit! *
By typing in your full name below, you are acknowledging that the information provided above are true and accurate. *
You can find our consent forms for treatment/ consultations, financial agreements, notice of privacy act and HIPAA compliance as well as office policies at www.catawbanaturalhealing.com.They are listed under New Clients. By typing in your full name, you acknowledge that you have read those forms and agree to the terms listed under them. If you have any questions, you may call us at 828-999-4800 or email us at healthservices@catawbanaturalhealing.com. *
By typing in your full name below, you acknowledge that a credit card must be kept on file once Dr Lor has agreed to take you on as her client. You also acknowledge that there is a no show or less than 24 hour cancellation fee for all appointments. After a total 3 no shows, less than 24 hour cancellations or a combination of the two, we will discharge you as a client from our practice.

There is a $200 fee for your first missed appointment. 
There is a $75 fee per missed follow up appointment. 
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Please type your full name if you understand the below:
I understand that Dr. Lor is a Naturopathic doctor in the and a licensed Acupuncturist. She is not a primary care doctor, gynecologist, dermatologist, or esthetician. She can not make Western diagnosis nor prescribe prescriptions in the state of NC. In hoping to work together, I understand that Dr. Lor may provide me with Naturopathic health coaching and Traditional Chinese Medicine therapies. 
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