New Patient Form

These forms are necessary for both new and returning clients who would like a wellness evaluation. The following documents must be reviewed and completed.

Client Intake Form: Complete your name, address, phone number, who referred you, etc.


WE USE a logic driven system using both objective (lab data) and subjective (questionnaires) designed for individuals who would like a wellness evaluation. A personal 7 day tabulated diet record and supplement list provides a critical snapshot of your nutrient intake. From this data, you receive a personalized report and schedule a consult WITH Dr. Brouse by phone. The following list of documents must be completed and returned before your report can be produced.

  1. Client Intake Form: Complete your name, address, phone number, etc. and sign and date form to accept terms for report evaluation.
  2. Lifestyle and Symptom Survey – Answer questions that allow Dr. Brouse to quickly and concisely capture your current symptoms and health history.
  3. My Fitness pal – Summarize your food intake for seven days.  This can be done the week before, during or after your blood draw.
  4. Monthly Nutrition and Lifestyle Log – A concise form that allows you to keep track of the most important aspects of your program and track your progress.

Adobe Reader – Get your free copy of Adobe Acrobat Reader!  We post our downloadable documents as Acrobat files. If you do not have Acrobat, download it now so you can view these links. 

If you have additional questions, call Julie at 503-631-4184.

Dr. Richard Brouse

Dr. Richard Brouse

I am passionate about helping people gain control of their health. I accomplish this by designing individual programs including diet, exercise, stress management and the use of proven nutritional supplements to achieve this for my patients.

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