New Patient Information Form
Street Address Line 2
State / Province
Postal / Zip Code
List the top 5 complaints you have in the order of their importance:
Current medications/drugs being taken:
Are you currently under the care of a physician or other health care professionals? (If yes, please give name and date of last visit):
Nutritional supplements you are taking:
How many per day/week do you do of ... Cigarettes?
How many per day/week do you do of ... Coffee?
How many per day/week do you do of ... Alcohol?
How many per day/week do you do of ... Soda?
How many per day/week do you do of ... Gum/Mints?
List any major illnesses with approximate dates:
List any major surgeries with approximate dates:
Past accidents or injuries, including any head traumas:
Number of children (if any):
Any family history of serious illnesses (list those which apply): Cancer / Diabetes / Heart / Other (please list):
Any household pets or other animals you are in close contact with (please list all):
Please upload a somewhat recent photo of yourself (taken in the last year or two).
Is there any additional information you feel is important to share?
Should be Empty: