New Patient Questionnaire

Date *

Month Day Year
Full Name *

First Name Middle Name Last Name
Birth Date *

Month Day Year
Age
Genetic Background *

African American Native American Mediterranean Hispanic Caucasian Northern European Asian
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Cell Phone *

Area Code Phone Number
Secondary Phone

Area Code Phone Number
E-mail *
We require the following information for the purpose of our staff to use the most respectful language when addressing you
Preferred pronouns

He/Him/His She/Her/Hers They/Them/Theirs A pronoun not listed Decline to answer
Gender Identity

Male Female Trans-Male Trans-Female Non-Binary A gender not listed Decline to answer
Height
Weight
Right or left handed
Relationship status
Whom may we thank for your referral *

List current medications and supplements/herbs/vitamins and minerals
List major surgeries, illnesses, and broken bones you have had
How many bowel movements do you have each day
What are your main health concerns *
Did something trigger a change in health? *
Can you recall - when was the last time you felt well? *
What makes you feel better? *
What makes you feel worse? *
Please describe yur digestion - indigestion, reflux, pain, constipation, diarrhea, or any other symptoms
Female patients (males skip to next section):
Are you pregnant and due date
Date of last menstrual cycle
Please describe your menstrual cycle and PMS symptoms, if any
Describe your urinary flow. frequency, and urgency. Do you wake up during the night to urinate
Male patients:
Describe your urinary flow - urgency, frequency, weak strem, etc *
Do you experience Erectile dysfunction?
Additional Comments:

What do you commonly eat for breakfast
What do you commonly eat for lunch
What do you commonly eat for dinner
What are your snack choices
What are your beverage choices How many glasses of water to you drink each day
What type of exercise do you perform. How many times per week and for how long.
What stressors affect you. Some choices include work, finances, family, health, and relationships
Describe your sleep. please include how many hours, position(s), type of mattress, blankets, and pillow. Do you feel rested in the morning?
When you think about a health improvement program, what fears do you have
Please type your name with a / symbol before and after your name.
Should be Empty:

Female patients (males skip to next section):