Patient Forms

Please complete the first three forms and download any additional forms that apply to your current situation.  Thank you.

New Patient Intake

Please download and complete this form if you are a new patient to Dr. Herold or you have not been in for over three years.

Brain Region Form

Please download and complete this form to help Dr. Herold understand how different regions of your brain and functioning and may be influencing your current complaints.

Metabolic Assessment Form

Please download and complete this form to help Dr. Herold understand how your physiology and different organ systems are functioning and how they may be influencing your current complaints.

Immune Balance Assessment

Please download and complete this form if you have a condition that may involve autoimmunity, allergies or chronic infections.

Concussion Symptoms

Please download and complete this form if you have experienced any head trauma, whiplash or known concussion, even if you did not lose consciousness or directly hit your head.  Note there are two columns for each symptom.

Motor Vehicle Accident

Please download and complete this form if you have a case involving a motor vehicle accident.

Dizziness Vestibular Survey

Please download and complete this form if you experience issues with dizziness, vertigo, balance problems or other discoordination isues.

Functional Rating Index

Please download and complete this form if you suffer any neck or back pain so we can better understand and rate how it is impacting your daily activities.