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First Name
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Last Name
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Email
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Age
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Please enter a number from
0
to
99
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Date of Birth
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Month
Day
Year
Identifying Gender
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Services interested in
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Osteopathic Medicine
Functional Medicine
Both Osteopathic and Functional Medicine
What are the top three health concerns you would like Dr. Van Deven to help you overcome?
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Please summarize any information you feel is important as it relates to these conditions. Include date of onset, known or suspected causes, and previous treatment.
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Have you been evaluated and/or treated by another medical provider for this/these health concern(s)?
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No
Yes
Do you suffer from severe anxiety, depression, rage, bipolar, PTSD, OCD or any other mental health issues?
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No
Yes
Please provide details of anxiety, depression, rage, bipolar, PTSD, OCD or any other mental health issues.
Have you had any major diagnoses?
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No
Yes
Please provide details of any major diagnoses.
On a scale 1-10 How ready are you to:
(10 being I will do anything, 1 being I'm not that motivated)
Significantly modify your diet
10
9
8
7
6
5
4
3
2
1
Take nutritional supplements
10
9
8
7
6
5
4
3
2
1
Keep an updated health journal
10
9
8
7
6
5
4
3
2
1
Engage in relaxation techniques
10
9
8
7
6
5
4
3
2
1
Modify your lifestyle
10
9
8
7
6
5
4
3
2
1
Do regular laboratory work to evaluate your progress
10
9
8
7
6
5
4
3
2
1
To ensure comprehensive care, patients are required to have a separate primary care physician. Are you working with a physician now?
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Yes
No
Please take a moment to look through the website to familiarize yourself with the practice, including information about the approach and process. We do not accept insurance, although we will provide you with the necessary paperwork for you to seek reimbursement. Medicare and Medicaid will not reimburse for these services. Thereby, partnering with Dr. Van Deven is a financial investment in your health.
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Yes, I understand, and I have reviewed the
Rates and Services
.
How did you hear about Dr. Van Deven?
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About
The Approach
Osteopathic Medicine
Functional Medicine
Conditions Treated
FAQ’s
Rates and Services
Become a Patient
Testimonials
Contact
