Adult Intake Form

Adult Intake Form
Full Name

First NameLast Name
Date

MonthDayYear
Date
Date of birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Home Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
May we leave messages relating to your visits?

YesNo
Emergency Contact

First NameLast Name
Phone Number

Area CodePhone Number
Relation
How did you hear about our Clinic?

ReferalAdvertisementOther
Other health care providers you are seeing (Name, Address, Phone#)
Does your insurance provider cover Naturopathic Medicine?

YesNoUnsure
Medical History
What are your health concerns, in order of importance to you:
Are you currently pregnant?

YesNo
Please indicate any serious conditions, illnesses or injuries and any hospitalizations, along with approximate dates.
Do you have any allergies (medicine, animals, chemicals, food, etc.)?
Please list all current medications (prescription, over-the-counter, vitamins, herbs, homeopathics, etc.)
Do you regularly get screening tests done by a health care professional?

YesNo
Which ones?

Blood testsBone density scan (DEXA)MammogramPapDigital Rectal Exam (prostate exam)Fecal occult bloodOther
Do you frequently use any of the following?

LaxativesPain RelieversAntacidsAppetite SuppressantsAntidepressantsAntibioticsBirth control pills/implants/injections/patchCholesterol-lowering medicationUlcer medicationSleeping medication
Alcohol-how much/day or week
Tobacco-form and amount/day
Caffeine-form and amount/day
Recreational drugs-what how often
Please indicate what immunizations you have had

DPT (diptheria, pertussis, tetanus)Tetanus boosterMMR (measles, mumps, rubella)Haemophilus influenza B"Flu"PolioHepatitis AHepatitis BSmallpoxHPVVaricella (Chicken Pox/Shingles)
Please indicate if any caused adverse reactions:
Do you have any dietary restrictions?
Family History
Please indicate any family history of (Allergies, Asthma, Heart Disease, High Blood Pressure, Cancer, Depression, Mental Illness, Drug Abuse/Alcoholism, Kidney Disease, Other)
Environment
Occupation
Hobbies
Do you exercise regularly?

YesNo
What do you do for exercise, how much, how often?
Are you exposed to significant tobacco smoke (work, home, etc.)

YesNo
Are you frequently exposed to animals?

YesNo
Are you regularly exposed to toxins or other hazards (work, home, hobbies, etc.)? Please describe.
How would you describe the emotional climate of your home?
How stressful is your work, or other aspects of your life? How well do you handle these stresses?
Is there anything that you feel is important that has not been covered?
Naturopathic Care
Have you seen a Naturopathic Doctor before?

YesNo
What are your health related goals?
Should be Empty:

Adult Intake Form

Medical History

Family History

Environment

Naturopathic Care