INTEGRATIVE HEALTH PATIENT SELF-ASSESSMENT

INTEGRATIVE HEALTH PROGRAM

Ready to get started on your health and wellness journey? Fill out our patient self-assessment form!
PATIENT INFORMATION
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Email
example@example.com
Phone*
Height*
Weight*
Address*

Address

Street Address Line 2

CityState

Zip Code
Primary Care Doctor*
Primary Care Doctor's City/State*
Describe Current Problems:*
Have you tried any treatment?*
Has anything been successful?*

MEDICAL HISTORY
List past medical and surgical history. Type "N/A" if not applicable:*
List previous hospitalizations. Type "N/A" if not applicable:*
Do your parents or siblings have (or had) any health issues?*

YesNo
Please explain:*
How often have you taken antibiotics?*
How often have you taken steroids?*
List current medications. Type "N/A" if not applicable:*
List vitamins, minerals, and nutritional supplements you are currently taking. Type "N/A" if not applicable:*

INTEGRATIVE HEALTH PROGRAM