FORMS AND QUESTIONNAIRES

  STEP ONE: FORMS AND ONLINE QUIZZES

Please follow the instructions below, then click the appropriate button at the bottom to proceed to the next part.

Help your doctor get to know you!

Each individualized Nu-Living program begins with a powerful comprehensive evaluation: assessing the patient's symptoms, conditions, preferences, behavior, and much more. To accomplish this, Doctor Terlinsky has developed the following quizzes and questionaires:

Starting with "Medical History" below, please print-out and complete the (6) questionnaires. You will need to complete and bring these to your initial (assessment) appointment. (Note: If you fail to bring the completed forms to your first appointment, we may be forced to (due to time constraints) reschedule your appointment to a later date!)

It is necessary to complete all steps on this page in a single session (without reloading or refreshing your browser window). Click on each title below to open the document in a separate window. Most documents require "Acrobat", a popular plug-in that probably came with your computer. If you don't have Acrobat, simply (download free Acrobat here.)

TO PRINT: Open document, then (in your browser's menu) press the printer-ICON, OR select FILE, then PRINT. When finished printing, close the window by pressing the red "X" in the window's upper right-hand corner.

Forms & Questionnaires

Medical History
12 Reasons Why
Consent to Treatment
Appetite Suppression Consent
Patient Health Questionaire (PHQ) *
Weight & Lifestyle Inventory (WALI) *
* Large files - If you are using a dial-up (31-56kb) internet connection, these may require from 3-5 minutes to download

Next, please take a few moments to complete the following online questionaires. These can be challenging, but they are also very important to your evaluation. Your answers are forwarded directly to Doctor Terlinsky. Click on each Title/link below to begin the questionnaire:

Interactive Quizzes


Thank you for your patience and efforts! When you have printed the 6 forms and completed the 3 online quizzes on this page, please press the wide button below to proceed to Admission Step 2! (Cost & Policy Review)

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Getting to know you

Forms & Questionnaires

Interactive Quizzes

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