Integrative Health Consultation Intake Form

Integrative Health Consultation Intake Form

Ready to start your wellness journey? Please complete this intake form as thoroughly as possible. The form is used to learn about your unique healthcare needs. Print all information and mark anything you don't understand with a question mark. Add additional sheets as needed, and bring any lab tests or healthcare records that you want to have reviewed.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*

MaleFemale
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Primary Care Provider*
Primary Care Phone*
Please enter a valid phone number.
Primary Care Fax*
Please enter a valid phone number.

1. Review your Medications list to make sure it is up to date and includes ALL prescriptions you are currently taking. Please make sure to specify the exact brand, dose, and form of the medication you are actually taking. If one is missing, please list it in the box below.
List the medication(s) you are currently taking*
2. Review your Supplements list to make sure it is up to date and includes ALL supplements you are currently taking. Please make sure to specify the exact brand, dose, and form of the supplement you are actually taking. If one is missing, please list it in the box below.
List the supplement(s) you are currently taking*
3. List any testing you have had in the past 3-6 months (including genetic testing):*
4. Tell us your top 5 symptoms and/or goals for working with us:*
5. List your current diagnoses (if any):*
6. List any pertinent family medical history (e.g. autoimmune disease, cancer, heart disease, etc.)*

Permission and Authorization Form
Please read and review the pdf below containing our integrative health consultation terms and conditions.
Signature*

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Date*

MonthDayYear
Date
If patient is a minor, full name of parent or guardian (N/A if not applicable)*
Should be Empty:

Permission and Authorization Form