Patient Intake Form

Name*

First NameLast Name
Date of birth*

DayMonthYear
Occupation
Contact Information
Address:*

Street Address

Street Address Line 2

CityCounty/State/Province

Postal / Zip CodeCountry
E-mail that we will use to regularly communicate with you
Preferred phone number for communication*

Phone Number

Health Assessment and Medical Information
Current Height
Current Weight
Has your weight ever fluctuated by more than 5kgs in a short period of time?

YesNoI have struggled with my weight now for years
Please list any medications (including over the counter medication, birth control pill etc), supplements, vitamins or herbs you are currently taking. Please provide name, dose and duration
Any known allergies?

Men's Health

Women please skip to the next page
Are you sexually active?

YesNo
Please give your current method of contraception, if applicable
Do you have any problems with erectile dysfunction
Do you experience painful or difficult urination?

YesNoSometimes

What is your reason for coming to see a naturopath?
Thanks for taking the time to complete this intake form.
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