Patient Health History

Patient Health History
Demographic Information
Name*

First NameLast Name
Birthday*

MonthDayYear
Date
Age*
Gender
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Emergency Contact*

First NameLast Name
Emergency Contact Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship of Emergency Contact*
How did you hear about us?*

Internet searchSocial media postSubstackYouTubeReferred by a friendReferred by my doctorOther
Referring Physician or other person?

Current Medical History
What is the main reason for this appointment?*
Date of last complete check-up*

MonthDayYear
Date
Are you willing to modify your diet or living habits, if doing so would improve your health?*

YesNo
What is your biggest health goal?*
What would you like to accomplish in this visit?

Lifestyle and Habits
How many hours in a day do you ride in a vehicle?
How many hours per day do you watch television?
How many hours per day do you look at your phone, tablet, or computer?
How many hours per day do you scroll or engage on social media (eg Facebook, X (Formerly Twitter), Instagram, etc.)*
Is your work sedentary, active, or in-between?
How many times per week do you exercise?
How long do your exercise workouts last?
Specify minutes, hours
What sort of exercise are you doing currently?
For how long have you been doing regular exercise?
Indicate approximate number of years

Diet
Do you eat breakfast?

YesNo
What is a typical breakfast for you?
What is a typical lunch?
What is a typical dinner?
What do you snack on, if at all?
Is there variety in your diet, or do you tend to eat a lot of the same things?

VarietyA lot of the same

Supplements and Medications
Please list all current supplements and the dose per day you are taking:
If you are not taking any, just leave blank
Please list all current medications and the dose per day you are taking
If you are not taking any, just leave blank
Do you have any allergies to medications?*

NoYes
Please list any known allergies to drugs and the reaction you experience
Do you have any allergies to foods?*

NoYes
Please list any known allergies to foods and the reaction you experience

Signature and Acknowledgment
I hereby give consent for naturopathic / natural medical care at Nature Works Best Medical Clinic. I understand that my health insurance may or may not reimburse me for the charges at this clinic for my care, and that these charges are nevertheless due in full from me at the time of service. I understand that there is no guarantee of successful results.
Patient Signature
Should be Empty:

Rows	Past Problem	Current Problem
Frequent urination
Blood in urine
Recurrent bladder infection
Increased urge to urinate
Kidney stones
Genital sores
Incontinence
Sexual difficulty
Sexually transmitted infection
Difficulty urinating
Pain with urination
Genital discharge

Demographic Information