Welcome!

The German New Medicine offers a unique service to our members.

Our efforts are to make sure your experience is helpful, friendly and informative. Today, we will determine if German New Medicine can help you.

In order to do that, we need to do the following …

1) Review your intake questionnaire (below.)

2) If you would like to consult with Dr. Smookler, a membership contract must be signed prior to your first scheduled consultation. The membership contract may be accessed under the “Contact/Membership Contract” tab.

All information provided is confidential. It is held in the strictest of confidence and is considered private, privileged communication.

 

Your Name (required)

Mailing Address

Age (required):

Date of Birth:

Marital Status:

Occupation: Ages of Children:

Your Email (required)

Cell Phone Number (required)

Who referred you to Dr. Smookler:

What do you understand about the research you have done on German New Medicine?
What is the diagnosed medical condition and or health issues that you wish to discuss?
What surgeries have you had and when?
What medical treatments have you had? Chemotherapy? Radiation?
Was there a relapse after therapy?
What medications are you taking?
Are you on any pain medication? What kind?
Do you have copies of your medical tests and reports?
Blood tests?
Written reports of CT scans of the body?
Written reports of MRI scans?
Biopsy reports?
Other?
What alternative treatments have you done or are doing now?

If Female:

Menopausal?
Hysterectomy?
On birth control pills?
Sterilization due to chemotherapy?
At what age did menses begin?

If Male:

Hormonal changes - PSA test for prostate
Do you have night sweats? What time during the night do they occur? (4-5 am?)
If yes, when did you last have them

Laterality Determination:

Do you clap with your right hand on top of you left hand?
Do you clap with your left hand on top of you right hand?
Do you cradle a baby's head in your right arm or your left arm?
Are your hands cold?
Are your hands warm?
Do you have trouble getting to sleep until 3 am?
Do you wake up at 3 or 4 am and can't get back to sleep?
Do you have trouble sleeping at night?
Do you have constant thirst?
Is your output of urine less than the fluids you consume within a 24 hour period?
Are your feet swollen?
Is there ascites?
Is there pleural effusion?
Are any internal organs enlarged?