• Dr. Zee's Clinic - Naturopathic Intake

    Dr. Zee's Clinic - Naturopathic Intake

    Comprehensive Self-Help Health Education. Learn more at www.naturopathic.org
  • Format: (000) 000-0000.
  • Date of Birth*
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  • Blood type (select 2 options if known)*

  • Physical

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  • Current Healthcare Team

    Are you seeing anyone else for help?
  • When was the last time you had a blood test done?
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  • Lifestyle

  • Rows
  • How often have you taken antibiotics?*

  • Vaccinations

  • Did you receive your childhood vaccinations?*
  • Rows

  • Allergies

  • Do you have any environmental allergies or sensitivities? (pollen, detergent, etc.)*
  • Do you have any drug allergies or sensitivities? (pharmaceuticals, plants, etc.)*
  • Do you have any food allergies or sensory issues? (smell, taste, sound)*
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  • Sexual Health

  • Have you ever been tested for a sexually transmitted disease?
  • Rows

  • Medical History

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  • Medical Health

  • Rows
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  • Gynecological History

  • Rows
  • Gynecological History cont.
  • Male history
  • Dental history
  • Which educational recommendations would you like for yourself in your plan?*
  • What is your budget for labs? We have over 1000 biomarkers available for testing. This will help us know how comprehensively we can test*
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  • Date
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