New Patient Intake Form Packet

In order to minimize time spent in the waiting room filling out forms and to allow Dr. Weyrich to review your case prior to meeting with you, all new patients making an appointment to see Dr. Weyrich should download, print, fill out, and fax back to Dr. Weyrich at (888) 391-0414 one of the following files prior to your first visit (right click button to Download):

Please fill out and bring all original pages with you to your appointment.



Inexpensive Ways to Get to Know Dr. Weyrich

As mentioned by Dr. Weyrich on the Healthy House Call Radio Show with Dan Koontz on KFNX 1100, Dr. Weyrich offers inexpensive non-patient telephone consultations starting at $25 per 15 minutes payable through PayPal to determine whether Dr. Weyrich would be a good fit for your health care needs, and to make an initial assessment of needed lab testing and other documentation. No diagnosis or treatment can be prescribed during this initial phone call. Follow-up visits and testing after Dr. Weyrich has reviewed your file will be billed separately, at a cost commensurate with the duration of the required office visits (initial visits are typically $150, and Follow-up visits $75).

To schedule an telephone consultation or an in-office visit, please leave a message at:

In order to make most efficient use of your telephone consultation and/or initial office visit, please arrange to provide Dr. Weyrich with copies of any lab tests you have had in the past year, as well as filling out the above forms, as appropriate to your condition.



Metabolic Symptom Survey Form

Patients with concerns regarding thyroid or adrenal function should download, print, fill out, and fax back to Dr. Weyrich at (888) 391-0414 the following form prior to your visit:


Basal Body Temperature Form

Patients with concerns regarding thyroid or adrenal function should download, print, fill out, and fax back to Dr. Weyrich at (888) 391-0414 the following form prior to your visit:

Ideally, women who are cycling should start recording data on the morning after the onset of their menses.

You need a good quality thermometer of the type used for natural family planning. Generally the slower a thermometer responds, the more repeatable and reliable the temperature measurements will be. A couple models that appear to be best in class can be purchased by following the following links.

The glass thermometer below is the best choice for axillary temperatures, but not as convenient to use.

The digital thermometer below is more convenient, but has short battery life.


Iodine Patch Test Form

Patients with concerns regarding thyroid or adrenal function, or iodine deficiency should download, print, fill out, and fax back to Dr. Weyrich at (888) 391-0414 the following form prior to your visit.

DO NOT APPLY TINCTURE OF IODINE TO YOUR SKIN IF YOU HAVE A KNOWN SENSITIVITY TO IODINE OR ARE ALLERGIC TO SHELLFISH OR CONTRAST DYE!

The required 2% tincture of iodine is available at most drug stores, or can be purchased online:


Functional, Acupuncture and Traditional Chinese Medicine Pattern Screening Forms

Female patients wishing to be evaluated for patterns of imbalance according to the principles of Traditional Chinese Medicine should download, print, fill out, and fax back to Dr. Weyrich at (888) 391-0414 the following form prior to your visit.

The form for male patients is currently under construction.



Nutritional Assessment Questionnaire (NAQ) Form

This is included in the "New Patient Packet (complex, chronic, or functional case)" paperwork above:


Female Hormone Intake Forms

This form is included in the "New Patient Packet (Female Wiley Protocol)" paperwork above. Female patients wishing to be treated for infertility should download, print, fill out, and fax back to Dr. Weyrich at 480/393-4179 the following form prior to your visit.

The form for male patients is currently under construction.