Please fill out the patient intake form before you come in for your first appointment with Dr. Dae.  This will allow her to be more prepared for your appointment with her. 

If you have not already made your appointment on-line you can click here to go to the appointment schedule.

Name *
Name
Address *
Address
Gender *
Cell Phone *
Cell Phone
Home Phone
Home Phone
Date of Birth
Date of Birth
Phone of Emergency Contact *
Phone of Emergency Contact
Please list all of the reasons you want to work with Dr. Dae including mental, emotional and physical ailments.
MEDICATIONS
Have you taken antibiotics in the last year?
MEDICAL/HEALTH HISTORY
Has your weight changed more than 10 pounds in the last 6 months
Doctor's Phone
Doctor's Phone
Date of last full physical exam
Date of last full physical exam
FAMILY HISTORY
Please check if you or a member of your family has a history of any of the following dieases
Allergies
Alcoholism
Anemia
Anxiety
Asthma
Arthritis (Rhematoid)
Arthritis (Osteo)
Cancer
High Cholesterol
Depression
Diabetes
Epilesy
Heart Disease
Hepatitis
High Blood Pressure
Kidney Disease
Mental Disorders
Nervous Disorders
Obesity
Stroke
Thyroid Disorder
DIETARY/LIFESTYLE
Coffee
Tobacco
Alcohol
Drugs
Antacids
Aspirin
Red Meats
Chicken
Fish
Vegetables
Fruits
Dairy
Water
Sodas/Sweet beverages
Starch - Rice/potatoes
Wheat - Bread
Chips/Nachos
Cereal
Desserts/Sweets
Please rate you stress level for the following
Please rate you stress level for the following
m work life is joyous and easy
my home life is joyous and easy
my relationship with my significant other is joyous and easy
my relationship with my children is joyous and easy
my health related concerns are joyous and easy
my extracurricular activities are joyous and easy
SLEEP HABITS
What time do you wake up?
What time do you wake up?
EXERCISE HABITS
For how long do you exercise
For how long do you exercise
WOMEN'S HEALTH HISTORY
Do you use
Please check all that apply
Premenstrual Sypmtoms
Please rate the severity of your premenstrual symptoms
Please indicate here
Do you have recurring vaginal or bladder infections
Do you have a current or past history of:
BREAST HISTORY
Do you have a history of
MENOPAUSE
Do you have any of the following symptoms:
BIRTH CONTROL
What forms of birth control have you used or are using