Naturopathic adult form

Preferred First Name

Name of Parent/Guardian if Under 18

Date of Birth

Occupation

Email(Required)

Home Phone

Mobile Phone

Work Phone

How did you hear about us?

Were you referred by someone? If yes, whom?

Emergency Contact

Emergency Contact Name

Phone

Relationship

Medical Information

Name of Medical Doctor

Doctors Phone Number

Date of Last Visit

Health Information

Age

Height

Weight

What are your Health Concerns in order of Importance:(Required)

Most important, Second most important, etc

Please list all prescription medications currently taken including dose, frequency, and duration of use

Please list all over the counter medications you are taking (ie. aspirin, tylenol, antacids, etc)

Please list all supplements and herbal remedies you are currently taking including dose and frequency

Do you have any allergies? (medications, foods, environmental)

Approximately how many courses of antibiotics have you taken over the last 5 years?

Do you smoke or have you smoked in the past? If so, how much and for how long?

Do you currently, or have you in the past used recreational drugs? If yes, what type and how often?

Please list any serious illnesses, hospitalizations or surgeries, along with approximate dates

Please list significant health concerns of family members (including siblings, parents, aunts, uncles, and grandparents)

Do you have any dietary restrictions we should know about? (ie. vegetarian, vegan, religious, lactose intolerance, celiac disease, etc.)

Please describe your typical daily diet:

Breakfast:

Lunch:

Dinner:

Snacks:

Beverages:

Do you exercise? If so, please indicate type, frequency, and duration.

What are the main stressors in your life?

Please Indicate Your SKIN Symptoms from the List Below

If needed, please write any comments/explanations for your skin symptoms

Please Indicate Your HEAD Symptoms from the List Below

If needed, please write any comments/explanations for your head symptoms

Please Indicate Your EYE Symptoms from the List Below

If needed, please write any comments/explanations for your eye symptoms

Please Indicate Your EAR Symptoms from the List Below

If needed, please write any comments/explanations for your ear symptoms

Please Indicate Your NOSE Symptoms from the List Below

If needed, please write any comments/explanations for your nose symptoms

Please Indicate Your MOUTH AND THROAT Symptoms from the List Below

If needed, please write any comments/explanations for your mouth and throat symptoms

Please Indicate Your NECK Symptoms from the List Below

If needed, please write any comments/explanations for your neck symptoms

Please Indicate Your CARDIOVASCULAR Symptoms from the List Below

If needed, please write any comments/explanations for your cardiovascular symptoms

Please Indicate Your RESPIRATORY Symptoms from the List Below

If needed, please write any comments/explanations for your respiratory symptoms

Please Indicate Your DIGESTIVE Symptoms from the List Below

How often do you have bowel movements?

If needed, please write any comments/explanations for your digestive symptoms

Please Indicate Your FEMALE Symptoms from the List Below

Age menses began

Average Cycle Length (ie 28 days)

Average number of days of bleeding

Last Menstrual Period

Last PAP test

If you use(d) birth control, what type?

If you use(d) birth control, what was the duration?

Number of pregnancies

Number of live births

Number of miscarriages

Number of abortions

If needed, please write any comments/explanations for your female symptoms

Please Indicate Your MALE Symptoms from the List Below

If needed, please write any comments/explanations for your male symptoms

Please Indicate Your URINARY Symptoms from the List Below

If needed, please write any comments/explanations for your urinary symptoms

Please Indicate Your MUSCULOSKELETAL Symptoms from the List Below

If needed, please write any comments/explanations for your muskuloskeletal symptoms

Please Indicate Your PERIPHERAL VASCULAR Symptoms from the List Below

If needed, please write any comments/explanations for your peripheral vascular symptoms

Please Indicate Your NEUROLOGICAL Symptoms from the List Below

If needed, please write any comments/explanations for your neurological symptoms

Please Indicate Your ENDOCRINE Symptoms from the List Below

If needed, please write any comments/explanations for your endocrine symptoms

Please Indicate Your BLOOD & LYMPHATIC Symptoms from the List Below

If needed, please write any comments/explanations for your blood & lymphatic symptoms

Please Indicate Your EMOTIONAL Symptoms from the List Below

If needed, please write any comments/explanations for your emotional symptoms