Intake Form

welcome to the Forster Integrative Intake form :
below you can fill out our online intake form – or If you would prefer, you have the option to

Download the PDF version of this form
Download the HIPAA Release form
Download the Notice of Privacy Practices

    African AmericanNative AmericanMediterraneanHispanicCaucasianNorthern EuropeanAsianOther

    Check all the factors that apply to your current lifestyle and eating habits:

    Fast eaterStruggle with eatingLove to cookNegative relationship with foodLove to eat"Eat because I have to" issuesErratic eating patternsEmotional eaterEat too much/overeatEat fast food frequentlyLate night eatingLive or often eats aloneConfused about food/nutritionTime constraintsFamily members have different tastesDislike "healthy food"Rely on convenience itemsPoor snack choicesDo not plan mealsTravel frequentlyVeganVegetarianMacrobioticHigh ProteinOrganicLocalRaw FoodsStandard American Diet (USDA)Gluten-FreeGluten/Casein Free

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    I am solely responsible for the decision to see Dr. Danielle Forster, DO for Integrative and Regenerative medicine. I recognize that some recommendations may not prove to be successful. I understand some recommendations may be novel. I agree to participate in an active manner, monitor my progress, and report any concerns to Dr. Forster. I also understand that any significant symptoms should be reported to Dr. Forster immediately. I understand that Dr. Forster does not practice primary care medicine. I agree to maintain a relationship with my own primary care physician for general medical needs. I understand that Dr. Forster does not practice chronic pain management with opioid analgesics.

    By entering your name, you certify that the information you have provided is accurate and that you acknowledge the paragraph above.