New Patient Survey

Hello! Thank you for your interest in joining Swan Integrative Health and Wellness. We are a small specialty practice and do our best to place potential patients with the provider who is the best fit based on your needs. By filling out this brief survey, we will determine if you are a good match for the clinicians in our practice who are currently accepting new patients. If you do not hear from us, you will be placed on a waiting list and we will contact you when we have more availability. We are always growing and expanding so that we can help as many people in our community as possible. Thank you for understanding!

Please answer the following questions to the best of your ability.

Thank you!

Name(Required)

First Last

Email Address(Required)

Enter Email Confirm Email

Phone Number

Your Age(Required)

If you have health insurance, enter the name of your insurance carrier here:

Which program are you interested in joining?(Required)

Swan Integrative Health and Wellness (for general integrative women’s health care)

Swan Peri/Menopause Care Collective (for specialized perimenopause and menopause care)

This field is hidden when viewing the form

What is the MAIN issue that you would like to address with your clinician at Swan Integrative Health and Wellness:(Required)

What is the MAIN issue (or issues) that you would like to address(Required)

If there is another issue you'd like to address that isn't listed above, please describe it below

Please list all current supplements and medications

Have you had a routine gynecological exam in the past 2 years?

How motivated are you to make changes in your lifestyle (nutrition, activity, stress management, sleep, etc):

Extremely motivated – I'm willing to do what it takes to feel better!

Somewhat motivated – I have some hesitations about making major changes in my routine but am willing to start slow.

Not very motivated – change is hard for me and I am comfortable in my current routine. I would think about making a few small changes.

Not motivated at all – I'm not currently willing to make any changes OR I don’t think that I need to make any changes in my lifestyle.

How did you hear about us?

Friend/family member

Referral from another medical professional

Instagram

Facebook

Natural Nutmeg

Internet search

Other

If you chose "Friend/family member" above, please give us their name so we can say thanks!

If you chose "Referral from another medical professional" above, please let us know their name.

Thank you for your submission! Please note that we are not a primary care office and require our patients to have a primary care provider in the community. We look forward to meeting you!

New Patient Survey

Interested in becoming a patient?