Forms

Fibromyalgia Impact Questionnaire – The Fibromyalgia Impact Questionnaire is used to assess the degree of fibromyalgia type symptoms on your daily activities. This form can be used to establish your baseline symptoms as well as monitor symptom improvement over time.

Health Assessment Questionnaire – The Health Assessment Questionnaire is a questionnaire specifically designed for patients with rheumatoid arthritis or other auto-immune condition. It is used to self report the impact of disease on your daily activities. Use this form as a baseline assessment of your health or to monitor improvement from different treatments.

New Patient Form – Child (6-12) – This form is to be completed prior to your first appointment with Dr. Wilkinson. Please complete and mail, fax, or deliver this form to Arthritis Health at least 3 business days prior to your appointment. This form is to be used for CHILDREN aged 6 – 12 years old.

New Patient Form – Child (0-5) – This form is to be completed prior to your first appointment with Dr. Wilkinson. Please complete and mail, fax, or deliver this form to Arthritis Health at least 3 business days prior to your appointment. This form is to be used for CHILDREN aged 0 – 5 years old.

Medical Symptom Questionnaire – This form allows you to rate your symptoms over the last 30 days to provide a baseline before treatment is started as well as for comparison after treatment.

Diet Diary – This form is used to complete a diet diary of food consumed during a 7-day period. Dr. Wilkinson uses this information to understand your current diet as well as monitor progress in your dietary changes.

Metabolic Assessment Form – The Metabolic Assessment Form is used to understand functional areas (e.g., blood sugar control, hormones, adrenal function, gastro-intestinal issues) that may be causing your health issues. Fill out this form based on your current level of symptoms. This will help direct Dr. Wilkinson to the most appropriate area to start treatment.

Gluco Graph – This form is used to track your blood sugar several times a day over multiple days. Dr. Wilkinson will use your blood sugar readings on this form to establish your baseline blood sugar control, pinpoint problem times of the day or meals, and to monitor your improvement.

Homeopathic Intake Form – Adult – This form is for an adult homeopathic intake with Dr. Wilkinson. This is to be completed only if you and Dr. Wilkinson have chosen to use homeopathy in your care. Please send this completed form in atleast 3 business days prior to your homeopathic appointment.

Homeopathic Intake Form – Child – This form is for a child homeopathic intake with Dr. Wilkinson. This is to be completed only if you and Dr. Wilkinson have chosen to use homeopathy in your care. Please send this completed form in atleast 3 business days prior to your homeopathic appointment.

Patient Application – Axelrod – This is the application to start the Ultra-Lite program with Dr. Axelrod. Please complete this form and bring to your first Ultra-Lite appointment.

Questionnaire History – Axelrod – This form is part of the initial medical history needed to start the Ultra-Lite program with Dr. Axelrod. Please complete this form and bring it to your first Ultra-Lite appointment.

Case CBT – Rheumatology - Do not read this form until the first day of your rotation. The case will be discussed during your residency.

Requirements for Residents – Rheumatology - This form states the requirements for your rheumatology rotation. Please read the form in preparation for your resident rotation.

Suggested Rheumatology Topics – Rheumatology - This form contains topics to learn about for your rotation. This is a baseline for you to learn and be better prepared for your time here.

Visiting Resident Information Sheet – Rheumatology - This is the information sheet. It is to be completed and brought to your first day of your rotation.