New Patient Inquiry Form

Written by Dr. Jonathan Peterson, Updated on January 17th, 2018

Quality of Live Evaluation
Please fill out these questions as accurately as possible.
*Must be 30 or older and a US Citizen/Resident*

Your Name:

Your Location:

Your Email:

Your Phone:

Best Time To Contact ?

Do you suffer from any of the following motivation/energy related symptoms ?

  • I have to read things many times before I understand it?
  • I feel a strong need to sleep during the day?
  • I have to struggle to finish task?
  • I have to force myself to do all of the things that need doing?
  • I often have to force myself to stay awake?
  • It takes a lot of effort for me to do a simple task?
  • I have to push myself to do things?
  • I feel worn out even when I have done nothing?
  • I often feel too tired to do the things I ought to do?
  • My memory lets me down?

 Yes No

If you answered yes please elaborate:

Do you suffer from any of the following emotional/social symptoms?

  • I often feel lonely even with other people?
  • It is difficult for me to make friends?
  • I have a difficult time controliing my emotions?
  • I often lose track of what I want to say?
  • I feel as if i let people down?
  • I lack confidence?
  • I find it hard to mix with people?
  • There are times when I feel very depressed?
  • I find it difficult to plan ahead?
  • I avoid responsibility when possible?
  • I am easily irritated by other people?
  • I feel as if i am a burden to people?

 Yes No

If you answered yes please elaborate:

Please list any medications you are currently taking:

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Name (*)
Email (*)
Phone (*)
Select A Program (*)
Select US State (*)
Select Age (30+ only)
Confirm over 30 years old (*)  Yes
Confirm living in the USA? (*)  Yes
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