Dr. Maria's office offers the patient form(s) online so they can be completed in the convenience of your own home or office. If for some reason, you are not able to complete the forms online, notify the office. In this case, you will need to arrive 15-30 minutes early for your appointment in order to fill them out.

Patient Health History Form

*must be completed by all patients, except children (ages 12 and under)

The above link will allow you to submit your information electronically to our office, make sure to click the SUBMIT button at the bottom of the page.

*If you would rather Print the Patient History Form to fill out and bring into the office, please use this link. (use above link if you intend to fill the form out online to submit directly)

Be sure to check out the contact page to see where we are located.

If you would like to use your health insurance, scroll down and print the insurance verification form. You will need to call your insurance company and ask each question on your form. If you find it is to your benefit to utilize insurance, we will provide you with all the necessary forms.

Metabolic Assessment Form (form may take a moment to load)

  • Fill this form out if you feel you are not 100% well! This is a basic assessment of organ and/or endocrine function. It helps the doctors determine where to begin your healing.

Brain Health and Nutrition Assessment Form (form may take a moment to load)

  • Fill this form out if you experience depression, anxiety, insomnia, memory loss or just want to know how to improve/preserve your brain health. This is useful to prevent brain degeneration and/or improve emotional well being.
  • Please print and bring this form with you to the office.

Brain Function Assessment Form

  • This form helps the doctor determine which areas of the brain may be malfunctioning
  • Fill this form out if
    • you have ever suffered a concussion
    • you have anxiety or depression
    • you feel your brain does not function as well as it used to
    • you have neurological problems
    • you want to slow down aging of your brain
  • Print and bring form with you to your appointment

Brain Region Assessment

  • This form helps determine what areas of the brain are starting to degenerate or have been impacted by insults such as concussion or toxin
  • Fill this form out if you have had a brain insult
  • Fill this form out if you are concerned about memory loss and/or age related effects on the brain
  • Fill this form out if you are concerned about overall brain health

NeuroToxic Questionaire

  • Many of us have been exposed to chemicals that can accumulate and cause health problems. This form will help the doctor determine if biotoxins may be affecting you.
  • Biotoxins include mold, lyme, chronic viruses (herpes, epstein barr) and chemicals
  • If you have odd or unexplained symptoms this may be the answer

Pediatric Health History Form

  • Required for infants and children under 12 (form may take a moment to load)

    Many things can occur early in life that cause maladaptions of the nervous system.

    Please print and bring this form with you to the office. Do not email it.

  • Child Neurotransmitter Form (form may take a moment to load)

    Many children are showing signs of ADD, anxiety and other behavioral problems. This assessment helps the doctor determine if there is a nutritional imbalance or brain chemistry imbalance that needs support. This can significantly improve the child's adaptation to their environment.

  • Please print and bring this form with you to the office.

Insurance Verification Form If you would like us to bill insurance on your behalf, print this form. Call your insurance company and fill out as much information on the form as possible. Bring it, email it or fax it to the office. Fax # 208 874-4300

Employment application

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