Patient Questionnaire Become a Patient Name * Email * Phone * Birth Date * Address * Who recommended you to this practice? Friend Doctor Google search Website Other Which provider would you like to see? Cindy Parks Jennifer Moss Rebecca Bolling Any Provider We accept the following types of insurance. We are not currently accepting Medicare or Medicaid patients due to the high volume we are currently caring for. Amy's Kitchen Cigna First Choice Health HST Technology MODA Primary Health Pacific Source Providence Health Plans Regence United HealthCare Do you currently have a primary care provider? Yes No If yes, who? If you have seen any medical specialists in the past three years, please list them here: What are the primary health conditions or health challenges you are seeking help with? If you take regular prescription medications please list them here: Text What is your biggest obstacle to achieving your health goals? Check all that apply: Lack of knowledge Lack of energy Need clarity about what may be helpful Lack of money Other What primary issue would you like to address at your first visit other than establishing care? Are you seeking an integrative medicine approach to your health care? If yes, briefly in a sentence or two, share why this is important to you. Thank you so much for reaching out. If you have any other comments, please write them here. We'll be in touch shortly. Submit If you are human, leave this field blank.