• The following information will kickstart your health journey towards

    holistic wellness & beauty.

    Let's get started!

  • INTEGRATIVE DERMATOLOGY

    INTEGRATIVE DERMATOLOGY

    PATIENT'S FORM

  • Personal Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Marital Status*
  • Person/s to Contact In Case of Emergency*
  • Main concern/s for consultation*
  • How ready are you to change your lifestyle? (5-most ready)*
  • What are your top 3 health goals?*

  • Medical History

    Please supply the following information in brief statements.
  • Do you have any allergies?*
  • If yes, cite them below.
  • Do you have any food intolerance? *

  • Food intolerance is difficulty digesting a certain type of food and having an unpleasant reaction after eating them (ex. bloating, abdominal pain, gas, diarrhea, nausea).

  • Food Intolerance
  • Current Skin, Hair or Nail Problems*
  • Kindly post photos of affected areas here.
  • Have you been hospitalized before?*
  • If yes, please list your previous hospitalizations (include even the ones during your childhood).
  • Have you had any medical procedures/treatment done to your skin, hair and nails in the past 2 years?*
  • If yes, please state them below.
  • Do/did you have any medications (oral and topical)?*
  • If yes, please indicate your previous & current medications.

  • Birth History

    The following questions pertain to your birth history. Please try to answer as many questions as you can.
  • Did your mother experience any complications during her pregnancy with you? *
  • What was your mother's diet/food preference during her pregnancy with you?*
  • Were you born...*
  • Were there any birth complications?*
  • Were you breastfed as an infant?*
  • What was your diet/food preference during your childhood?*

  • Family History

  • Significant Medical Conditions in the Family*
  • List of Family Members Who Have Passed (If applicable, please include grandparents, parents, siblings and cousins)

  • Lifestyle

  • What is the nature of your career/profession?*
  • Which meals are these?*
  • How long does it usually take you to finish one meal?*
  • Which one do you prefer?*
  • How do you usually feel after having a meal?*
  • Do you engage in any of the following?*

  • Nutrition

  • Did you experience any recent changes in your diet or eating habit?*
  • Do you weigh yourself regularly?*
  • Please take a full body photo of yourself. This will be used to know your body fat distribution. *
  • What does your daily diet usually contain?*
  • Your meals are mostly...*
  • Do you read the food labels before purchasing them?*
  • Do you cook?*
  • Do you consider yourself an emotional/stress eater?*
  • Please check the box that corresponds to your usual drinking habit.*
    Rows
  • Do you have any food allergies?*
  • If yes, please state them below.

  • Exercise

  • Do you exercise?*
  • What type of exercise/sport do you engage in?

  • Coping With Stress

  • Do you have any hobbies?*
  • If yes, please state them.
  • How do you feel about your current financial status? (5-very happy)*
  • How happy are you with your current job/career? (100-very happy)*
  • Are you pleased with your social life? (5-very pleased)*
  • Are you satisfied with your current state of health? (5-very satisfied)*

  • Sleeping Habits

  • How can you describe your usual sleep? You may check more than 1 item.*
  • If you would like to further describe your sleeping habits/experience, please use the space below.
  • How do you usually feel when you wake up?*
  • Like and follow us on social media.
  • Image field 175
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