Dr. Deborah Bernstein - Holistic Healing Center


All the following are downloadable fill in PDF forms except for the Patient Consent Form and Office Policies. In order to be scheduled for an appointment, you must first complete the forms and drop off, mail or e-mail them to our office. The forms will take approximately 45 minutes to complete; once we receive your completed forms, we will contact you to schedule your appointment.

Very Important! To avoid emailing blank forms, after filling out forms on line, do not click the top right download button as it does not save the information you typed. Please follow instructions below for saving the forms.

If you are mailing your forms via USPS, please be sure to keep a copy for your records in the event they do not reach our office.

If you choose to e-mail your forms:

  • Fill in the forms and then save the completed form to your computer as a PDF by right-clicking and choosing “Print.”
  • Then Under “Destination,” change to “Save as PDF,” then click “Save.”
  • After the forms have been saved to your computer, check them to be sure the information saved correctly.
  • Attach the files to an e-mail and send to HHCforms@gmail.com.

     Preparing for your visit with Dr Bernstein

Patient Information Form

Patient Consent Form  (Please read and send in with all forms)

Office Policies (Please read and send in with all forms)

Medical Symptoms Questionnaire

Adult Medical Questionnaire Part 1   (Very important)

Adult Medical Questionnaire Part 2

Diet Assessment Questionnaire

Three Day Food Journal (Recommended)

We recommend that you print and fill out the following insurance information form and bring it with you to your first visit.  It will help us to provide you with guidance on billing for services and various routine and specialty lab testing the Doctor may order.

          Help us Help you with your Insurance

The following may be filled out periodically to monitor progress:

Medical Symptoms Questionnaire

Diet Assessment Questionnaire


To prepare for your visit with the Integrative Functional Nutritionist Faith Lumpkin:

          Three Day Food Journal




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