Naturopathic Consultation Intake Form

Current Client Form - Retune Intake Form

Naturopathic and Functional Medicine Intake Form – Dr. Keri Brown, ND
Thank you for taking the time to fill out this extensive form. It will provide valuable information about your health. Please SIGN and CLICK SEND at the end of the form.
Date

MonthDayYear
Date
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Birthday*

MonthDayYear
Date

DESCRIBE YOUR HEALTH - If you could erase 5 problems, what would they be? Example: 1. Fatigue 2. Sleep issues 3. Constipation 4. Diabetes
Height (feet/inches)
What is your current height?
Weight (current)
What is your current weight?
Last Blood Work Date
example 8/2020
Any abnormal blood results? What were they?
List blood or test results that are either high or low.

List Nutritional Supplements (Vitamins/Minerals/Herbs/Homeopathic:)
List all supplements you are currently taking.
List Medication (Prescribed or over the counter and what they are used for.)
List all medications you are currently taking.

The following sections review several different body systems relating to your health.

Each section relates to a different part of your health and gives us a big picture of your overall system.

INSTRUCTIONS: Fill out each section by CHECKING the circle if your symptoms apply.

Check either MILD, MODERATE or SERVER regarding what you have been feeling.

Do not check any box if it does not relate to you.

GROUP 1 - Sympathetic ANS - CHECK ONLY THE BOXES which apply to you.

Rows	MILD (1) symptoms (occurred once or twice last 6 month)	MODERATE (2) symptoms (occurred once or twice last month)	SEVERE (3) symptoms (chronic, occurs weekly)
Get chilled often
“Lump” in throat
Pulse speeds after meals
Keyed up – fail to calm
Cut heals slowly
Gag easily
Urine amount reduced
Heart pounds after retiring
“Nervous” stomach
Appetite reduced
Cold sweats often
Fever easily raised
Skin sensitive to touch
Sour stomach often

GROUP 2 - Parasympathetic ANS - CHECK ONLY THE BOXES which apply to you.

Rows	MILD (1) symptoms (occurred once or twice last 6 month)	MODERATE (2) symptoms (occurred once or twice last month)	SEVERE (3) symptoms (chronic, occurs weekly)
Joint stiffness on arising
Muscle-leg-toe cramps at night
“Butterfly” stomach, cramps
Eyes blink often
Eyes or nose watery
Eyelids swollen, puffy
Indigestion soon after eating
Always hungry; “lightheaded” often
Digestion rapid
Vomiting frequent
Hoarseness frequent
Breathing irregular
Pulse slow; feels “irregular”
Gagging reflex slow
Difficulty swallowing
Constipation, diarrhea alternation
‘Slow starter’
Gets ‘chilled’ infrequently
Perspire easily
Circulation poor, sensitive to cold
Subject to colds, asthma, bronchitis

GROUP 3 - Blood Sugar - CHECK ONLY THE BOXES which apply to you.

Rows	MILD (1) symptoms (occurred once or twice last 6 month)	MODERATE (2) symptoms (occurred once or twice last month)	SEVERE (3) symptoms (chronic, occurs weekly)
Eat when nervous
Excessive appetite
Hungry between meals
Irritable before meals
Get ‘shaky’ if hungry
Fatigue, eating relieves
’Lightheaded’ if meals delayed
Heart palpated if meals delayed
Overeating sweets upsets
Awaken few hours’ sleep – hard to get back to sleep
Craves candy or coffee in afternoon
Moods of depression – ‘blues’
Abnormal craving for sweets or snacks

GROUP 4 - CV System - CHECK ONLY THE BOXES which apply to you.

Rows	MILD (1) symptoms (occurred once or twice last 6 month)	MODERATE (2) symptoms (occurred once or twice last month)	SEVERE (3) symptoms (chronic, occurs weekly)
Hands and feet go to sleep easily
Sigh frequently, ‘air under’
High altitude discomfort
Opens windows in closed rooms
Susceptible to colds and fevers
Afternoon ‘yawner’
Get “Drowsy” often
Shortness of breath on exertion
Dull pain in chest, worse on exertion
Nose bleeds’ frequently
Noises in head, or ‘ringing in ears’
Tension/tightness under breastbone

GROUP 5 - Liver and GB System - CHECK ONLY THE BOXES which apply to you.

Rows	MILD (1) symptoms (occurred once or twice last 6 month)	MODERATE (2) symptoms (occurred once or twice last month)	SEVERE (1) symptoms (chronic, occurs weekly)
Dizziness
Dry skin
Burning Feet
Itching skin and feet
Frequent skin rashes
Bitter, metallic taste in mouth in morning
Bowel movement painful or difficult
Worrier feels insecure
Headache over eyes
Greasy food upset
Stools light colored
Skin peels on foot soles
Pain between shoulder blades
Use laxatives
Stools alternating from soft to watery
History of gallbladder attach or gallstones
Dreaming, nightmares type bad dreams
Bad breath (halitosis)
Milk products causes distress
Sensitivity to hot water
Burning or itching anus
Craves sweets

GROUP 6 - Gastrointestinal System - CHECK ONLY THE BOXES which apply to you.

Rows	MILD (1) symptoms (occurred once or twice last 6 month)	MODERATE (2) symptoms (occurred once or twice last month)	SEVERE (3) symptoms (chronic, occurs weekly)
Flatulence/Gas after eating - p
Foul-smelling gas – p
Stomach ‘Bloated’ after eating - c
Burning sensation, better eating - c
Lower Abdominal gas – c
Constipation alternating Diarrhea – c
“Gurgle” Feeling in Abdomen - c
Queasiness/Nausea/Vomiting – f
Burping or Belching – f
Upper Abdominal Pain – f
Constipation, not having a bowel movement a day
Diarrhea, explosive
Esophageal Reflex
Low back pain/disk
Right-sided hip pain (comes and goes, reoccurring)
Left-sided hip pain (comes and goes, reoccurring)
Tongue coated white
Tongue coated yellow

GROUP 7A - Endocrine System: Thyroid - CHECK ONLY THE BOXES which apply to you.

Rows	MILD (1) symptoms (occurred once or twice last 6 month)	MODERATE (2) symptoms (occurred once or twice last month)	SEVERE (3) symptoms (chronic, occurs weekly)
Insomnia
Nervousness
Can’t gain weight
Intolerance to heat
Highly emotional
Flushes easily
Night sweats
Thin, moist skin
Inward trembling
Heart palpitates
Increased appetite without weight gain
Pulse fast at rest
Eyelids and face twitch

GROUP 7B - Endocrine System: Thyroid - CHECK ONLY THE BOXES which apply to you.

Rows	MILD symptoms (occurred once or twice last 6 month)	MODERATE symptoms (occurred once or twice last month)	SEVERE symptoms (chronic, occurs weekly)
Increased weight gain
Decreased in appetite
Fatigue easily
Ringing in ears
Sleepy during the day
Dry or scaly skin
Constipation
Mental sluggishness
Hair course falls out
Headaches upon arising, wear off during the day
Slow pulse, below 55
Frequency of urination
Reduced initiative
Finger nails brittle
Elbow pain

GROUP 7C - Endocrine System: Pituitary - CHECK ONLY THE BOXES which apply to you.

Rows	MILD (1) symptoms (occurred once or twice last 6 month)	MODERATE (2) symptoms (occurred once or twice last month)	SEVERE (3) symptoms (chronic, occurs weekly)
Failing memory
Low blood pressure
Increased sex drive
Headaches, ‘splitting or rending’ type
Decreased sugar tolerance

GROUP 7D - Endocrine System: Pituitary - CHECK ONLY THE BOXES which apply to you.

Rows	MILD (1) symptoms (occurred once or twice last 6 month)	MODERATE (2) symptoms (occurred once or twice last month)	SEVERE (3) symptoms (chronic, occurs weekly)
Abnormal thirst
Bloating of abdomen
Weight gain around hips or waist
Sex drive reduced or lacking
Tendency to ulcers, colitis
Increased sugar tolerance
Women: menstrual disorder
Young girls: lack of menstrual function

GROUP 7E - Endocrine System: Adrenals - CHECK ONLY THE BOXES which apply to you.

Rows	MILD symptoms (occurred once or twice last 6 month)	MODERATE symptoms (occurred once or twice last month)	SEVERE symptoms (chronic, occurs weekly)
Dizziness
Headaches
Hot flashes
Increased blood pressure
Hair growth on face and body (female)
Sugar in urine (not diabetes)
Masculine tendencies (female)

GROUP 7F - Endocrine System: Adrenals - CHECK ONLY THE BOXES which apply to you.

Rows	MILD (1) symptoms (occurred once or twice last 6 month)	MODERATE (2) symptoms (occurred once or twice last month)	SEVERE (3) symptoms (chronic, occurs weekly)
Weakness, dizziness
Chronic fatigue
Low blood pressure
Nails weak, ridged
Tendency to hives
Arthritis tendencies
Perspiration increases
Bowel disorder
Poor circulation
Swollen ankles
Craves salt
Brown spots or bronzing of skin
Allergies – tendency to asthma
Weakness after colds, influenza
Exhaustion – muscular and nervous
Respiratory disorders
Dizziness upon standing
Knee pain

GROUP 8 - Stress Related B Vitamin - CHECK ONLY THE BOXES which apply to you.

Rows	MILD (1) symptoms (occurred once or twice last 6 month)	MODERATE (2) symptoms (occurred once or twice last month)	SEVERE (3) symptoms (chronic, occurs weekly)
Apprehension
Irritability
Morbid fears
Never seems to get well
Forgetfulness
Craving for sweets
Depression, feeling of dread
Noise sensitivity
Acoustic hallucinations
Poor appetite
Tendency to cry without reason
Hair is course and/or thinning
Weakness
Skin sensitive to touch
Tendency towards hives
Nervousness
Headaches
Insomnia
Anxiety
Inability to concentrate, confusion
Frequent stuffy nose, sinus infection
Loose joints
Tongue has cracks or crack down center

GROUP 9 - FEMALE ONLY QUESTIONS - CHECK only the boxes which apply to you.

Rows	MILD (1) symptoms (occurred once or twice last 6 month)	MODERATE (2) symptoms (occurred once or twice last month)	SEVERE (3) symptoms (chronic, occurs weekly)
Polycystic ovaries
Menopausal hot flashes
Very easily fatigues
Premenstrual tension
Painful menses
Depressed feeling before menstruation
Menstruation excessive and prolonged
Menstruate too frequently
Menstruation scanty or missed
Vaginal discharge
Vaginal dryness
Vaginal smell
Hysterectomy/ovaries removed
Menopausal hot flashes
Painful breasts
Acne, worse at menses
Depression of long standing
Fibrocystic breast

GROUP 9 - MALE ONLY QUESTIONS - CHECK only the boxes which apply to you.

Rows	MILD (1) symptoms (occurred once or twice last 6 month)	MODERATE (2) symptoms (occurred once or twice last month)	SEVERE (3) symptoms (chronic, occurs weekly)
Thumb pain
Urination difficult or dribbling
Night urination
Depression
Pain on inside of legs or heels
Feeling of incomplete bowel evacuation
Lack of energy
Migration aches and pains
Tires to easily
Avoids activity
Legs nervousness at night
Diminished sex drive
Enlarged prostae
Prostate infection
Impotency
Difficulty obtaining an erecting
Loss of control of urination

Take Photo of your Face. (without Makeup)
Take Photo of your Tongue.
Take Photo of your Finger Nails.
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