Patient Forms

PATIENT FORMS

A completed Patient History form and a Symptom Survey Form are required when you see Dr. Leff for the first time. You may download and print the two-page Patient form as well as the Symptom Survey Form and complete them at your leisure, but please bring the completed forms with you on your first visit.

These forms are available for you to download in Adobe PDF format. You may then open the forms in Adobe Acrobat Reader, print them on your printer and complete the information. Please note that you are not able to type into these forms and email them to us, all pages must be printed, completed and brought to the office on your first visit.

Please follow these instructions to download a copy of each form requested by Dr. Leff:

  • Right Click on the form name
  • select the “Save” option
  • Remember the name of the folder to which you are saving the file
  • Launch your Acrobat Reader program
  • open the file
  • print the number of pages indicated for each form

PatientHistory Form (two pages)

Symptom Survey Form (five pages)

Menopause Questionnaire (one page)

Thyroid Questionnaire (one page)Biotoxicity Questionaire (one page)

Symptoms for Saliva Test (two pages)

Symptoms for Bloodspots (two pages)

Note: If you do not have the Abobe Acrobat Reader program, you may download a Free copy by Clicking Here.