Health History Intake Form

Health History Intake Form

Please complete the following questions carefully. All information is confidential to ensure your privacy.
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age
Height
Weight
Birth Date

MonthDayYear
Email Address
Contact Number
Format: (000) 000-0000.
TextEmail
Emergency Contact
Contact Number
Format: (000) 000-0000.
Occupation
How did you learn about our services? Who may we thank for the referral?
Are you currently receiving healthcare by a MD/Naturopath/Homeopath/ Chiropractor/Massage Therapist etc?
List major health concerns, and reason for visit.
Do you have any known allergies or sensitivities?
List of medications: Please list all you’re now taking regularly including over the counter medications:
Supplements:
Do you take digestive aids/laxatives? If yes, what do you take? How Often?
When was the most recent time that you took antibiotics? Why?
Recent Surgeries: Please list any surgeries within the last six months:
C-sectionGallbladderGastric BypassHysterectomyColonOther
NormalAcid RefluxBloatingBurning pain in stomachGasUlcersConstipationDiarrheaFeeling of heavinessFoul smelling stoolsOther
YesNo
3 per day2 per day1 per daySkip days
Requires strainingEffortless
Only after eatingIt varies
NormalToo littleToo large
NormalToo hardVery softDiarrhea
BrownBlackGreenishOrange/yellowWhitish/grayish
Lots of mucusLots of gasFoul smelling
YesNoNot Sure
Do you have hemorrhoids or other rectal problems (itching, fissures, etc.?) Please describe:
Do you work in a profession that prevents you from using the bathroom? Please explain:
YesNoNot Sure
YesNo
If you had them removed, when and was it removed safely?
Did you have any detoxification protocol prior and after removal?
YesNo
Do you suffer from headaches/migraines? If so, how frequently:
YesNo
YesNo
YesNo
Exercise: Please describe your exercise routine with type of exercise, duration and frequency:
How do you feel on this routine?
If you don’t exercise, what do you feel is holding you back?
Do you experience any pain, stiffness or swelling?
Water: How much water do you drink per day?
Do you drink coffee, sodas, fruit juice/drinks, iced tea/hot tea or alcohol? If so, how much in one day?
Rest: What is your average amount of sleep per night?
Any problems sleeping? If yes, please explain:
Stress: On a scale of 1 to 10 where “1” is mellow and “10” is stressed out:
Please rate your current stress:
What are your main sources of stress?
If your stress level is 5 or more, what steps are you taking in managing and reducing your stress?
Do you take vacations?
What is your greatest joy?
What is your greatest fear?
How do you envision your future-both career goals and personal dreams?
Energy: On a scale from 1 to 10, “1” = “can’t get out of bed” and “10” = “optimal energy” Please rate your energy level:
Does your energy vary depending on time of day? Please explain:
Junk food/fast food eaterCombination eater (from junk foods to health conscious)VegetarianVeganMacrobioticRawWhole foods eater (80% organic)Paleo dietBlood type dietOther
Blood type, if known:
How many servings of fresh fruits and vegetables to you eat daily?
How much Dairy do you eat per day?
How much Meat do you eat per day?
How much Wheat do you eat per day?
Are you open to making dietary changes?
Do you have any food cravings? If so, what?
Spiritual Enrichment: How many hours of spiritual enrichment do you receive each week? (Prayer, bible study, church, meditation, choir,etc)
Toxin Exposure: Do you smoke?
Describe your work environment:
Describe your home environment:
Do you have any water filtering system installed in the house?
Shower filter?
Any exposure to metal/poisons/chemicals/toxins/mold/electricity/electromagnetics through work, home, or hobbies?
Family History (Please list health issues, and age and cause of death if applicable)
Father:
Mother:
Siblings:
Maternal Grandmother:
Maternal Grandfather:
Paternal Grandmother:
Paternal Grandfather:
Other relatives (aunts/uncles cousins with relevant health history, if applicable):
Pre-Menopausal Women: Do you experience PMS?
Do you experience painful and/or difficult menstruation?
Do you experience frequent urinary tract and/or yeast infections?
Was there a specific event that occurred just before the first onset of your current symptoms that may have triggered them (e.g.an illness, grief, sadness, shock, vaccination, medication.)
Is there any other useful information that you can provide that will better enable us to assist you, or you feel would be beneficial for the practitioner to be aware of?
I acknowledge that Naturopathic Solutions and all staff members are NOT medical doctors. I understand that Naturopathic Solutions may provide nutritional and other health related information to assist in educating me towards attaining and maintaining my best health. Naturopathic Solutions staff may refer you to other service providers depending on your needs. I understand that Naturopathic Solutions, as well as staff members of Naturopathic Solutions, do NOT diagnose, evaluate, treat, or claim to cure any illness or disease. I have been made aware of all contraindications for the therapy I am receiving and am here on this day, and any subsequent visit, by my choice and solely on my own behalf. I hereby release and discharge Naturopathic Solutions from any claims in which I, or my agents/employees, ever had, now have, or may have had relating to or arising out of services provided or information that I have received. I acknowledge that it is my responsibility to consult with my physician, or other health care providers, relating to any disease or condition that I may have.

I give permission to share my health information with other health care practitioners who are also providing services for my care. I am not a minor.
Signature
I am signing this release voluntarily.
Signature
Date

MonthDayYear
My signature below indicates that I have honestly answered all the questions above and supplied any additional relevant information with this intake form.
Signature
Date

MonthDayYear
Date
Should be Empty: