Clinic Tools

This page is for Clinic Staff to assist in providing Lifestyle Medicine patients the optimal experience.

For Dr. Drozek

Guidelines for Referrals for clinic staff

Recipes for Shared Medical Appointments

Recipe schedule template

Patient Forms

New Patient Intake Form

     To be completed at first appointment.  Please have patient complete this before doing the intake.  Take the form to the provider for review while the patient is having intake. 

Follow Up Check In Form 

      To be completed by the patient on the day of the appointment BEFORE being brought back for vitals!  Give this to the provider for review while the patient is being prepped for visit.

Driving Directions to the Classes

Provider Forms 

(will be printed and utilized by Dr. Drozek)

For Individual Appointments

Individual Encounter Form:

     To be scanned in as a progress note after an individual encounter.

Patient Resource Checklist:

      Maintained by the provider for individual patients to remind what educational resources have been utilized, and should be scanned in after each encounter.


Group Visit Consent Form

     To be signed before the first shared medical appointment encounter.

LMP Study Consent

     Dr. Drozek will ask his patients to sign this.

Assessment Tools


     ACE Scoring


Red Flags for Sleep Disorders

Food Checklist

Food Diary 

Curb the Cravings

Are you ready for health?

Lifestyle Medicine


                                                                                                 Memorial Health System



Office: 740-592-4229

FAX: 740-592-4010

2019 MHS NOWORDS horizontal CMYK large EXPECT MORE v1
© David Drozek 2014