Intake Forms
Welcome New Patients
At Fenske Holistic Healthcare LLC, we appreciate the trust you have placed in us to work together with you to regain and maintain your health. We pride ourselves in our commitment to our patients. We look after each patient as we would the closest member of our family.
After calling our office to schedule your initial appointment, please complete the appropriate forms provided below. Based on the initial appointment you scheduled you would select forms for either Chiropractic, or one of the levels of Functional Medicine. Initial Functional Medicine appointments will require a Request for Medical Records form to be returned to our office within 2 days of scheduling your appointment so Dr Fenske can review your medical history before your appointment. You may download the forms from our website and print them, fill them out and return by mail or fax, or scan them and email them to Info@DrFenske.com. Please keep a copy of any mailed forms in case we do not receive them. The Patient Acceptance Form below gives detailed information on what Functional Medicine patients can expect leading up to, and during their initial office visits. If you have problems downloading the forms we can email or mail them to you, or you may pick up blank forms in our office.
Chiropractic AND Functional Medicine patients please send us your paperwork one week prior to your initial appointment (email to Info@DrFenske.com, fax to 608.836.8863, mail or drop off at the address below). Although completing the paperwork will take time, the more I know about you the better I will be able to assist you.
We look forward to a long and positive relationship with you. Please consider us your family holistic healthcare office and do not hesitate to ask us how we can be of help in any and all circumstances regarding your health and the health of your family.
Dr. Nicole Fenske
A Note About Chemical Sensitivity
During your visit to our office please be aware that many of our patients are sensitive to the chemicals and/or other ingredients used in PERFUMES, HAIR SPRAYS, and other SCENTED BODY PRODUCTS.
Out of respect for these patients please restrict the use of these products when visiting our office. Thank you!
Intake forms for new Chiropractic patients
NOTE: Dr Fenske is NOT currently accepting new CHIROPRACTIC patients.
Chiropractic Intake Forms: Patient Information
Chiropractic Intake Forms: Health History
Both completed forms due one week before your initial appointment.
Intake forms for new Functional Medicine – LEVEL 1 & 2 patients
To_Do_List (FM – Level 1 and 2)
Use this to help you prepare your intake forms.
Request for_Medical_Records (FM – Level 1 and 2)
So that we may request your past medical records from other providers with time for Dr Fenske to review them, please return this form AS SOON AS YOU SCHEDULE your initial appointment.
Patient_Acceptance and Information Form (FM – Level 1 and 2)
Please return these pages 3 weeks prior to your initial appointment.
Patient Health History (FM – Level 1 and 2)
Please return these pages 3 weeks prior to your initial appointment.
Diet Diary (FM – Level 1 and 2)
Please return these pages 3 weeks prior to your initial appointment.
Intake forms for new Functional Medicine – LEVEL 3 patients
To_Do_List (FM – Level 3)
Use this to help you prepare your intake forms.
Request for Medical Records (FM – Level 3)
So that we may request your past medical records from other providers with time for Dr Fenske to review them, please return this form AS SOON AS YOU SCHEDULE your initial appointment.
Patient_Acceptance and Information Form (FM – Level 3)
Please return these pages 3 weeks prior to your initial appointment.
Patient Health History (FM – Level 3)
Please return these pages 3 weeks prior to your initial appointment.
Diet Diary (FM – Level 3)
Please return these pages 3 weeks prior to your initial appointment.
Intake forms for Laser Therapy
Patient_Acceptance and Information Form
Patient Health History
Please return both of these forms prior to your initial appointment..
Intake forms for Health Coaching
If you are seeing our Health Coach, please bring both of these forms to your first appointment.
Health Coaching Informed Consent Form
Have questions about any of the forms? Please call our office at (608) 836-8883
Privacy Policy
Notice of Privacy Practices – Click here to see how we protect your personal information.