Naturopathic Intake Form

Date
Date
1. Name *
1. Name
Context of Care
The nature of your response to the following questions will go a long way in assisting my understanding of your truest desires. Your time, thoughtfulness and honesty in completing this overview will greatly aid me to assist your health needs.
Rate from 0 to 10, 10 being 100% committed
Health
7. Are you currently receiving health care?
Since when? Getting better or worse? List as many as you can
9. Are you seeing or have you seen any other health practitioners for these conditions?
10. Have you seen another naturopathic doctor in the past?
11. Do you have any known contagious diseases at this time?
FAMILY HISTORY
12. Do you or anyone in your family have a history of any of the following?
Check all that apply
14. Do you take or use any of the following?
Check all that apply
16. Any known allergies/hypersensitivities:
17. Have you been vaccinated?
Diet
(religious, vegetarian, vegan etc)
Stress, Energy & Sleep
10 = high stress
10 = optimal energy
23. Do you have difficulty falling asleep?
24. Do you have difficulty staying asleep?
10 = good sleep
Medications and Supplements
28. Check any of the following that apply:
Medical History
29. Eyes
Have you ever suffered from any of the following? Check all that apply
30. Ears
Have you ever suffered from any of the following? Check all that apply
31. Nose/Sinus
Have you ever suffered from any of the following? Check all that apply
32. Mouth/Throat
Have you ever suffered from any of the following? Check all that apply
33. Neck
Have you ever suffered from any of the following? Check all that apply
34. Respiratory
Have you ever suffered from any of the following? Check all that apply
35. Cardiovascular
Have you ever suffered from any of the following? Check all that apply
36. Blood
Have you ever suffered from any of the following? Check all that apply
37. Endocrine
Have you ever suffered from any of the following? Check all that apply
38. Gastrointestinal
Have you ever suffered from any of the following? Check all that apply
39. Genitourinary
Have you ever suffered from any of the following? Check all that apply
40. Urination
Have you ever suffered from any of the following? Check all that apply
41. Female Reproductive
Have you ever suffered from any of the following? Check all that apply
Menstrual cycle
Days from start of bleeding to start of next bleeding.
Are you pregnant?
(If yes, please tell us below how many months)
Do you perform self breast exams?
42. Male Reproductive
Have you ever suffered from any of the following? Check all that apply
Do you perform self testicular exams?
Are you sexually active?
43. Mental/Emotional
Have you ever suffered from any of the following? Check all that apply
44. Muscle/Joint/Pain
Have you ever suffered from any of the following? Check all that apply
45. Neurologic
Have you ever suffered from any of the following? Check all that apply
46. Skin
Have you ever suffered from any of the following? Check all that apply
47. Check any conditions you have had
Check all that apply