Cary Office Click To Call
(919) 865-0700
1110 SE Cary Parkway Ste # 206
Cary, NC 27518, USA | Directions
Cornelius Office Click To Call
(704) 765-3150
20905 Torrence Chapel Rd #201
Cornelius, NC 28031, USA | Directions
Please note that it is important to fill in all the fields before submitting. Thank you.
*Patient Last Name :
*First Name :
M.I. :
1. Do you have mercury / silver fillings?
Yes No
How many?
Since when?
2. Have any of your mercury / silver fillings been replaced?
Yes No
When?
With what?
3. Were your fillings removed using a rubber dam?
Yes No
Clean-up device Alternate breathing source
4. Did you have mercury / silver fillings in your baby teeth?
Yes No
How many?
5. Did you have all of your childhood vaccines?
Yes No
Do you currently take the flu vaccine?
Yes No
How often?
Any other boosters?
When?
6. Where did you grow up? (City / State)
7. Were you on or near farms?
Yes No
Herbicides / Pesticides / Insecticides :
8. Were you near large industry?
Yes No
Chemical plants Processing plants
9. What are all the jobs you have held? (List)
10. What hobbies have you done with paints or other chemicals / liquids?
11. Have you ever siphoned gasoline with your mouth or washed your hands in gasoline?
Yes No
12. Did you ever play or work in apple, peach, citrus or other orchards?
Yes No
13. Where you ever diagnosed with mercury or heavy metal toxicity?
Yes No
14. How was the diagnosis made?
Are there lab reports? (please provide copy)
Yes No
15. Have you been doing any detoxification?
Yes No
What kinds?
Under whose care?
How long?
Any problems?
16. What was the reason that you ended up with the diagnosis of heavy metal toxicity?
Do you have a diagnosed disease or disability thought to be related?
Yes No
What?
17. What was the reason that you ended up with the diagnosis of heavy metal toxicity?
Are you still seeing that provider?
Yes No
Are they supportive of alternative care?
Yes No
Do they know you are here?
Yes No
18. Who else do you see besides the provider who sent you here (if referred)? Please list
19. What are your beliefs or understandings about heavy metal toxicity?
20. What are your goals for being here?
*Signature:
Date: