Return to Intake Forms Patient Intake Form - Adult Step 1 of 6 16% URLThis field is for validation purposes and should be left unchanged.Personal InformationName First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Preferred Phone NumberGender Male Female AgePlease enter a number less than or equal to 99.Date of Birth MM slash DD slash YYYY Single or Married? Single Married Would you like to receive notices from our office? Yes No EmployerOccupationName of Emergency Contact PLEASE LIST THE HEALTH CONCERN/PROBLEM THAT BRINGS YOU IN TODAY:Health Concern / Problem #1Describe your concern or problem.When did this problem initially start to bother you?How often does it bother you -- hourly, daily, weekly, monthly?How severe on a scale of zero to 10 (10 being the worst/highest level)?What makes this problem better or worse, namely drugs or supplements, etc.?Anything else important about this problem you’d like to share?Add 2nd heath concern? Yes, add 2nd concern Health Concern / Problem #2Describe your concern or problem.When did this problem initially start to bother you?How often does it bother you -- hourly, daily, weekly, monthly?How severe on a scale of zero to 10 (10 being the worst/highest level)?What makes this problem better or worse, namely drugs or supplements, etc.?Anything else important about this problem you’d like to share?Add 3rd health concern? Yes, add 3nd concern Health Concern / Problem #3Describe your concern or problem.When did this problem initially start to bother you?How often does it bother you -- hourly, daily, weekly, monthly?How severe on a scale of zero to 10 (10 being the worst/highest level)?What makes this problem better or worse, namely drugs or supplements, etc.?Anything else important about this problem you’d like to share? Current MedicationsPlease list any prescription or over the counter medications that you are currently taking.Name of DrugDoseReason for TakingFor how longWho prescribed Add RemoveAllergic to any drugs or substances? What?Please list any vitamins, minerals, herbs or homeopathic remedies that you are presently taking Add RemovePlease list your current health care providers.NameTypeFor what reasonPhone (if available) Add RemoveHospitalizations, Serious Illnesses and InjuriesPlease list reason and dates, excluding non-surgical childbirthEventReasonDate Add RemoveDate of last full physical examExam DateResults (normal or other) Add RemoveDate of last blood workBlood work dateResults (normal or other) Add Remove(Females) Are you pregnant, or is there any chance that you are pregnant? Yes No Do you have any surgical implants? If so, what type and where in your body?Have you seen a naturopath before? Yes If so, how many other naturopaths have you seen?How long have you been interested in natural medicine? Lifestyle HabitsTobacco UsageFrequency (none, daily, weekly, monthly)Amount Add RemoveDo you any history of smoking? If so, how many years? What years?CoffeeFrequency (none, daily, weekly, monthly)Amount Add RemoveBlack TeaFrequency (none, daily, weekly, monthly)Amount Add RemoveSoft drinksFrequency (none, daily, weekly, monthly)Amount Add RemoveAlcoholFrequency (none, daily, weekly, monthly)Amount Add RemoveHistory of significant alcohol consumption or alcoholism?Please also provide how long and how much.Recreational drugsFrequency (none, daily, weekly, monthly)Amount Add RemoveHistory of significant recreational drug use?ExerciseFrequency (none, daily, weekly, monthly)Amount Add RemoveAre you currently sexually active?-How would you rate your libido (sex drive) on a scale of zero to 10?DietPlease describe your typical diet (breakfast, lunch, and dinner), including any guidelines or restrictions that you follow:BreakfastLunchDinner(Optional) Please describe briefly your religious and/or spiritual background/beliefs:History of Covid and Covid vaccineDo you recall when you might have contracted Covid? Approximate date(s) would be fineHave you received any Covid vaccines? If so, which one(s) and the date(s). Ideally list the exact date(s), but approximate date(s) will be fine too. Patient Profile - Review of Systems (Please answer carefully)“Y” means you have the condition now. “P” means that you had the condition in the past, but not any more. If you have never had a condition, leave it blank.GeneralHeightWeightWeight changes Y P Night Sweats Y P Fatigue Y P Fever Y P Mental / EmotionalDepression Y P Mood Swings Y P Anxiety or nervousness Y P Tension Y P Suicide thoughts Y P Suicide attempts Y P SkinAcne Y P Eczema Y P Hives Y P Rashes Y P Infection Y P Growths (such as warts) Y P Changes in hair/nails Y P Transdermal skin patches?EndocrineEver had any thyroid problem Y P Heat or cold intolerance Y P Hypoglycemia Y P Excessive thirst Y P Excessive hunger Y P Easy weight gain Y P HeadHeadache Y P Head Injury(such as warts) Y P CirculationDeep leg pain Y P Cold hands / feet Y P Varicose veins Y P EyesDryness Y P Glasses or contacts Y P Eye pain Y P Tearing Y P Double Vision Y P BloodAnemia Y P Easy bleeding or bruising Y P EarsImpaired hearing Y P Ringing (tinnitus) Y P Ear ache/itch Y P Dizziness Y P HeartHeart disease Y P High blood pressure Y P Rheumatic fever Y P Chest pain Y P Swelling in ankles Y P Palpitations, fluttering Y P Nose & SinusesFrequent colds Y P Nose bleeds Y P Stuffiness Y P Sinus problems Y P Post nasal drip Y P RespiratoryCough Y P Spitting up blood Y P Wheezing Y P Difficulty breathing Y P Shortness of breath Y P Positive TB test ever? Y P Mouth & ThroatFrequent sore throat Y P Sore tongue Y P Sores in mouth /on lips Y P Gum problems Y P Hoarseness Y P Dental Problems Y P Fake teeth? How many?How many amalgam (mercury) fillings?Dental implants?If yes, what type?Dental bridges or partial bridges?If so, are they metallic?Any metal of any kind in your mouth?DigestionTrouble swallowing Y P Heartburn Y P Take heartburn or acid reflux medicines?Bloating after eating Y P Change in appetite Y P Change in thirst Y P Loose stools Y P Blood in stools Y P Belching or gas Y P Liver/gall bladder disease Y P Hemorrhoids Y P Nausea Y P Vomiting Y P Bowels move daily more less Use laxatives? What kind?Eat plenty of fiber?UrinaryPain on urination Y P Increased frequency Y P Frequency at night Y P Inability to hold urine Y P Bladder infections Y P Swellings anywhere in body Y P FemaleAge menses beganNo. of days menstrual flowLength of complete cycleAre cycles regular Y P Bleeding between periods Y P Excessive flow Y P Cramps Y P PMS Y P Abnormal vaginal discharge Y P DATE of LAST PAP SmearResults were: normal abnormal don't know EVER had an abnormal PAP? Y P Date of last mammogram?Ever used birth control pills? Y P Ever used an IUD? Y P If so, how long?No. of pregnanciesNo. of live birthsNo. of miscarriagesNo. of abortionsMenopausal symptoms Y P Still have your own uterus? Yes or No? Yes No Still have your own ovaries? Yes or No? Yes No MusculoskeletalJoint pain or stiffness Y P Broken bones Y P Muscle spasms or cramps Y P Weakness Y P Date of last DEXA scan?BreastsDo you self exam regularly Y P Lumps Y P Pain or tenderness Y P Nipple Discharge Y P NeurologicFainting Y P Seizures Y P Paralysis Y P Muscle weakness Y P Numbness or tingling Y P Loss of memory Y P NeckSwollen glands Y P Pain or stiffness Y P MaleHernias Y P Testicular masses Y P Testicular pain Y P Discharge or sores Y P Venereal disease Y P Difficulty stopping or starting urination Y P Prostate problems Y P Date of last prostate exam Family HistoryIf you have any significant family medical history, please list them here. Examples: Cancer, heart disease, high blood pressure, diabetes, mental illness, stroke, alcoholism, etc. Please specify if the condition is on your mother's side versus father's side.Family Medical History DetailsProblem ListPlease list ANY or ALL medical conditions you have EVER been diagnosed with, starting from birth on?Personal Medical Conditions Add Remove Δ
