New Patient Registration Form

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please choose one *

Yes, I wish to receive email updates regarding events and news from GIAM and Dr. Gerson

No, I do not wish to receive email updates.

Sex *

Male

Female

Has annual deductible been met? *

Yes

No

Please check yes that you have read and understand the following: *

1. Full payment is expected at the time of your visit 2. All diagnostic procedures will be billed directly to your insurance company 3. Any procedure not covered by insurance will be the patient's responsibility. 4. Any cancellation within 24 hours will incur a charge of 50% of the office visit fee.

Yes

Please click yes that you have read, understand, and authorize and assign The Gerson Institute of Ayurvedic Medicine and Dr. Scott Gerson the following: *

1. I authorize Dr. Scott Gerson to furnish information to my insurance carrier concerning my medical treatment. 2. I assign the doctor all payments from my insurance company for any medical and/or diagnostic services rendered. I am responsible for the office visits.

Yes

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Sex *

Male

Female

Do you smoke? *

Yes

No

Do you drink alcoholic beverages? *

Yes

No

Do you drink coffee? *

Yes

No

Please check the following if they apply to you *

Allergies / Hay Fever, Etc

Asthma

Bowel Changes

Bronchitis

Chest Pain

Dizziness / Fainting

Gall Bladder Disease

Heart Murmur

Heart Palpitations

Hepatitis

Intestinal Disorders

Irregular Menses

Menopausal Symptoms

Rheumatic Fever

Sexually Transmitted Diseases

Shortness of Breath

Skin Rashes

Ulcers

Upper Respiratory Infections

Hypertension

None

Other

Which of the following styles most accurately describes how you perform your activities *

Quickly, with a lot of enthusiasm

With medium speed, intensely

More slowly and methodically

How easily do you become excited or enthused? *

Very readily

Fairly quickly

Not easily

How easily do you become frightened? *

Very easily

Fairly easily

Not easily

How quickly do you pick up new information? *

Very quickly, usually the first time

Quite quickly

More slowly, prefer to review materials several times

Which of the following best describes your memory? *

Good short-term, but tend to forget rather quickly

Medium, it depends

Good long term

Which of the following best describes your digestion? *

Quite easily upset; tendency towards gas and bloating

Virtually never a problem; can eat nearly everything with no discomfort

Digestion is slow; stomach feels heavy after long meals

Which of the following best describes your appetite? *

Irregular; varied

Strong; do not like to skip meals

Generally do not feel strong hunger; can easily skip a meal

How would you characterize your capacity for food intake? *

Varies a lot

Can eat a lot at one time without discomfort

Low

Which, if any, of the following groups of tastes do you specifically prefer? *

Sweet, sour, salty

Sweet, bitter (green, leafy vegetables), astringent (split peas, dried beans)

Hot and Spicy, bitter, astringent

None of the above

How would you describe your manner of speech? *

Fast, talkative, unsteady, feeble

Sharp, cutting, good speaker

Sweet, clear, rich, booming

Which, if any, of the following types of foods do you crave? *

Warm, cooked foods and hot drinks

Cold foods and drinks

Dry, crunchy foods

None of the above

Which, if any, of the following types of foods do you crave? *

Cold

Hot

Cold and damp

None of the above

Which of the following best describes your sleep patterns? *

Light sleeper, frequent awakening

Sound sleeper, need 6-8 hours

Deep sleeper, need more than 8 hours

Which of the following best describes your bowel habits? *

Irregular, not every day

More than twice daily

Regular, once every day

Towards which of the following do you have a tendency? *

Hard, dry stools

Loose stools

Formed stools

How easily do you perspire? *

Not easily, only when very hot

Easily, more than is comfortable

Very little, ever

How would you describe the strength of your sexual drive? *

Mild

Moderate

Strong

How do you feel inside when you run into some problem or difficulty? *

Worried, mind moving back and forth, anxious

Irritated, angry

Calm, stable and clear-minded

Which colors do you most prefer? *

Blue, brown, green

Violet, orange, red, yellow

White

Which of the following book/movie themes interest you the most? *

Adventure, science-fiction, travel

Action, combat, non-fiction

Romance and fantasy

Consent to be treated with alternative medical therapies. Click yes, that you have read, understand and agree to the information below

I hereby consent to be treated for my medical condition(s) with methods of treatment, which may not be considered usual or customary methods of treatment. As with any medical treatment, I clearly understand that there is no guarantee of cure or improvement of my medical condition(s) when using these methods of treatment. I have had time to ask all pertinent questions and they have been answered to my satisfaction. Furthermore, I understand Scott Gerson, M.D. is not to be considered my primary physician. I agree to establish a relationship with another orthodox (non-alternative) physician who is to be my primary physician and who will have the ultimate responsibility for my medical care. I understand that I am using the services of Scott Gerson, M.D., in order to add alternative medical treatments to the usual and customary medical treatments that I have obtained or agree to obtain from my primary conventional (non-alternative) physician. I agree to hold harmless Scott Gerson, M.D., The Gerson Institute of Ayurvedic Medicine, as well as any and all licensed massage therapists, independent contractors, and personnel from any present or future liability arising from any and all treatments or advice received by me at this facility at any time.

Yes