Iron Overload New Patient Intake Form

Confidential New Patient Information

Iron Overload Intake Form for Dr. Eric Lewis
Please fill out this form and submit it to our office at least 2 days before your consultation.

This form is mobile-friendly, but you may find it more convenient to use a computer with a larger screen and a keyboard.

We recommend filling this form out in one sitting as there's not a reliable way to save and come back to an incomplete submission. Allow for 20-30 minutes to complete the form.

Thank you, and we look forward to providing you with excellence in naturopathic healthcare!
General Information
Today’s Date

MonthDayYear
Name
Parent/Guardian Name (if patient under 18)
Birthdate

MonthDayYear
Gender
Street Address
City
State
Zip
Primary Phone
Format: (000) 000-0000.
Email address
example@example.com
Spouse/Partner’s Name
Children (Names/Ages)
Occupation
Hobbies/Interests
How did you hear about us?

Other
What made you decide to make an appointment with Dr. Eric Lewis?

Current Health Concerns
List, in order of importance, your major health concerns/what you wish us to address today:
1.
2.
3.
4.
5.

Current Medications: (include all prescription and over-the-counter medications, hormones, etc.)

Rows	Medication	Dose/Frequency	For how long?	For what reason?

Current Supplements: (include all vitamins, herbs, homeopathy, or other supplements)

Rows	Supplement	Brand	Dose/Frequency	For how long?	For what reason?

Current Health Concerns

Please list your current health care professionals:

Rows	Doctor/Practitioner	Specialty	Office Name	Office Phone Number

Please write down a general timeline of your health history. Starting from childhood, include all major illnesses, injuries, operations, hospitalizations, and other medical diagnoses.

Rows	Illness/Injury/Operation/Hospitalization/Diagnoses:	Year	Details/Notes

Please list any known allergies (Medications, Foods, Environmental, Chemical)

Iron Overload and Hemochromatosis
Bloodwork
Fill in fields below if you have the information, or feel free to upload your iron labs at the bottom of this page.
When you first found out you had elevated iron levels, do you recall what your highest ferritin level was? Did you have other iron levels tested at this time?
Initial or Highest Iron Levels
Add any additional details about your initial iron lab work (if applicable)
What does your most current lab work show?
Current Iron Levels
Add any additional details about your current iron lab work (if applicable)
Upload Bloodwork, Lab Tests, or Other Records Here
Below you may upload any labs or other medical records that you wish to share.

Iron lab tests are very important for me to see if you have them, and you may wish to share other pertinent lab tests, even if they are not related to iron:
File Upload

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General Health History
In addition to iron overload, have you been diagnosed with any other medical conditions? Do you have heart disease, diabetes, liver disease, arthritis, or any other significant medical diagnoses?
What treatments or therapies have you tried for these conditions? How have they worked for you?

General Diet, Nutrition, and Lifestyle Habits
Describe your typical breakfast, lunch, and dinner. Please note if you follow any special diets (vegetarian, low-fat, low-carb, gluten-free, paleo, keto, etc.). Have you made dietary changes since being diagnosed with iron overload? What challenges and questions do you have regarding diet and iron overload?
What do you drink during the day and how much? Coffee, tea, soda, water, juice, etc.
Do you drink alcohol? If so, how many drinks per day?
Do you use tobacco?
Do you exercise?
What type of exercise do you do?
How often do you exercise?
Your height
Your weight today
Do you consider yourself:
How well do you sleep at night?
How would you rate your general energy level? (1=low; 10=high)
How would you rate your general stress level? (1=low; 10=high)
What are your major sources of stress?

Last Page - Thank you!
How may we best be of service to you? Do you have any specific wishes, requests, or questions regarding your consultation that you would like us to know about?
Thank you for filling out this intake form! We really appreciate this information and will use it to help provide you with the best naturopathic care at your upcoming appointment.

Please hit "SUBMIT" to save this form and continue to the next steps.

You will also be directed to the next forms to be completed, including our Informed Consent Forms.
Should be Empty:

Confidential New Patient Information

General Information

Current Health Concerns

Current Health Concerns

Iron Overload and Hemochromatosis

Genetic Testing

Iron Overload and Hemochromatosis

Bloodwork

Upload Bloodwork, Lab Tests, or Other Records Here

Iron Overload and Hemochromatosis

Hemochromatosis Symptoms

Hemochromatosis Treatment

Hemochromatosis Diet, Nutrition & Lifestyle

General Health History

General Diet, Nutrition, and Lifestyle Habits

Last Page - Thank you!