"My husband and I were trying unsuccessfully to have a 2nd child. I just felt whipped, physically and emotionally.

Over the course of the past 5 years, I had seen countless doctors & tried everything (it felt like it anyway)—including Clomid— without even the glimmer of success. Everyone I saw always had the same puzzled look on their face—I felt like a freak.

The minute I started talking to Laura about my situation, I felt like finally someone 'got me.'

Plus, she was part therapist, always addressing the emotional aspects of my situation as well.

On March 12, 2011 I gave birth to my beautiful daughter Anna!

When I watch my daughter with her brother Michael, I feel convinced in my heart it would not have happened without Laura—her wisdom, knowledge, & insight are truly unique & her kindness is unmatched."

- Amy D.

Forms

The forms we use are presented here for your convenience.

New patients can download and print the initial intake forms (find the first 7 here from Patient Admittance through HIPPA Acknowledgement) and fill them out before they arrive at their first appointment in order to save some time.

• Patient Admittance Form [45KB PDF] - Basic intake information form for all patients.
• Patient Health Questionnaire [172KB PDF] - Basic health history and current condition form for all patients.
• Self-Assessment Health Profile [450KB PDF] - A multi-category checklist of symptoms grouped according to the practice of Traditional Chinese Medicine (TCM).
• Stress Questionnaire [155KB PDF] - A 9-dimensional checklist of various kinds of stress manifested in different life situations.
• Acupuncture Informed Consent Form [91KB PDF] - statement of your authorization, rights and responsibilities for acupuncture services by Dr. Mudrak.
• Chiropractic Informed Consent Form [93KB PDF] - statement of your authorization, rights and responsibilities for chiropractic services by Dr. Mudrak.
• HIPAA-Acknowledgment [131KB PDF] - Official notice of privacy practices in use by Dr. Mudrak as required by the Health Information Portability and Accountability Act of 1996.
• Work Injury Questionnare [90KB PDF] - relevant data for an work injury.
• Auto Injury Questionnaire [45KB PDF] - relevant data for an automobile accident.
• Menopause Rating Scale (MRS) [255KB PDF] - Instrument to measure effects of menopause holistically.