Downloadable Forms
for Dr. Weyrich
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New Patient Intake Form Packet
In order to minimize time spent in the waiting room filling out forms and to allow Dr. Weyrich to review your case prior to meeting with you, all new patients making an appointment to see Dr. Weyrich at Comprehensive Health Services should download, print, fill out, and fax back to Dr. Weyrich at 480/393-4179 the first 6 pages (New Patient Intake Form and Patient Communication Authorization) of the following file prior to your first visit. Please fill out and bring all original pages with you to your appointment.
Download New Patient Packet.
Internet/Radio Special Coupon Offer
As mentioned by Dr. Weyrich on the Healthy House Call Radio Show with Dan Koontz on KFNX 1100, Dr. Weyrich is offering a special consultation for $25. Complete the coupon below and any one or more of the following forms, fax them to Dr. Weyrich, and then call (480) 423-6952 to make an appointment for Dr. Weyrich to interpret the results of the form(s) with no further obligation. If, after meeting with Dr. Weyrich you wish to establish a doctor-patient relationship by having a physical exam and discussing a treatment plan, then it's all good. Otherwise - it was Dr. Weyrich's pleasure to have met with you.
Download Internet/Radio Special Coupon file.
Nutritional Assessment Questionnaire (NAQ) Form
All new patients with chronic (long-term) complaints should download, print, fill out, and fax back to Dr. Weyrich at 480/393-4179 the following form prior to your first visit:
Download NAQ file.
Metabolic Symptom Survey Form
Patients with concerns regarding thyroid or adrenal function should download, print, fill out, and fax back to Dr. Weyrich at 480/393-4179 the following form prior to your visit:
Download Metabolic Symptom Survey file.
Basal Body Temperature Form
Patients with concerns regarding thyroid or adrenal function should download, print, fill out, and fax back to Dr. Weyrich at 480/393-4179 the following form prior to your visit:Download Basal Body Temperature file.
Ideally, women who are cycling should start recording data on the morning after the onset
of their menses.
You need a good quality thermometer of the type used for natural family planning.
Generally the slower a thermometer responds, the more repeatable and reliable the
temperature measurements will be.
A couple models that appear to be best in class can be purchased by following the following links.
The glass thermometer below is the best choice for axillary temperatures, but not as convenient to use.
The digital thermometer below is more convenient, but has short battery life.
Purchase FairHaven Mercury Free Glass Basal Thermometer.
Purchase FairHaven Digital Basal Thermometer.
Iodine Patch Test Form
Patients with concerns regarding thyroid or adrenal function, or iodine deficiency should download, print, fill out, and fax back to Dr. Weyrich at 480/393-4179 the following form prior to your visit. DO NOT APPLY TINCTURE OF IODINE TO YOUR SKIN IF YOU HAVE A KNOWN SENSITIVITY TO IODINE OR ARE ALLERGIC TO SHELLFISH OR CONTRAST DYE:Download Iodine Patch Test file.
The required 2% tincture of iodine is available at most drug stores, or can be purchased online:
Purchase 2% Tincture of Iodine.
Acupuncture and Traditional Chinese Medicine Pattern Screening Forms
Female patients wishing to be evaluated for patterns of imbalance according to the principles of Traditional Chinese Medicine should download, print, fill out, and fax back to Dr. Weyrich at 480/393-4179 the following form prior to your visit.Download Traditional Chinese Pattern Recognition (Female) Form.
The form for male patients is currently under construction.
Fertility Intake Forms
Female patients wishing to be treated for infertility should download, print, fill out, and fax back to Dr. Weyrich at 480/393-4179 the following form prior to your visit.Download Female Fertility Questionnaire.
The form for male patients is currently under construction.
Copyright © 2007-2010 Dr. Weyrich. The information on this site is for educational purposes only. It is not intended to diagnose, treat or cure any disease or illness. The statements on this website have not been evaluated by the Food and Drug Administration. If you have a health concern or medical condition, consult a licensed healthcare provider. Dr. Weyrich is licensed by the State of Arizona to practice medicine (license number 07-1008).
This web page is http://www.DrWeyrich.com/forms.html - Phone Dr. Weyrich at (480) 423-6952