New Patient Forms

Below are downloadable forms that you can print out. Please fill these forms out PRIOR to your office visit. EVERY NEW patient should fill out the first form (1).  This will take about 10-15 minutes to fill out.

 

The homeopathic patient forms (2) take around an hour to fill out, and only need to be completed by patients who will be having their homeopathic case taken.  

 

The form for new cancer patients (3) will take 10-20 minutes

 

If you're not sure which forms to fill out, please contact us.  

 

(1)For ALL NEW PATIENTS (download, print, and fill out):

 

 

 

 

 

 

 

 

 

(2)ONLY for NEW HOMEOPATHIC patients (download, print, and fill out the above forms (1), AND the following 13-page form:
 

 

 

 

 

 

 

 

(3)For ALL NEW CANCER patients (download, print, and fill out the screening form in addition to the forms above for ALL NEW PATIENTS (1)). Please also strongly consider doing the Four drawings exercise: 

 

 

 

 

 

 

 

 

ALL PATIENTS:  PLEASE bring copies of recent tests and bloodwork to your appointment. 

If you've had testing done through any Cleveland Clinic facility, you can add Dr. Cseak to your list of physicians so that she can directly access your results.  Instructions for adding Dr. Cseak are as follows:

1. Log in to your MyChart

2. Go to the Menu, under ‘Sharing’, and click on ‘DrConnect Authorization’

3. Enter Dr. Cseak's details  (Karin Cseak, DO.   The practice name is Family Holistic Health.  Office phone number is 330-923-3060)

4. Hit the ‘Submit’ button

Dr. Cseak should have access to your records within a week.  

** PLEASE NOTE: We treat many people with serious sensitivities to perfumes, colognes, and other scents. Please refrain from wearing any of these products into the office.**