Naturopathy New Patient Form

Name

First Name Last Name

Date of Birth

Date

Phone Number

Area Code Phone Number

Email

example@example.com

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Who referred you to our office today? *

a friend/family member my doctor Google Facebook Eventbrite Meetup

If referred by a friend, family or doctor, please provide their name so that we may thank them:

Pick the top 3 symptoms (using the Symptoms page) you would most like to see relief from.

What are your life goals?

How much "sweaty" activity do you do weekly?

What type of activity is it?

How many ounces of water do you drink daily?

What type of water is it:

Which meals do you eat on a daily basis?

Breakfast Lunch Supper

How many eliminations per day on average?

How many digestive enzymes per day on average?

How many breathing exercises per day on average?

How much of the following do you consume? (example: 1D = once daily; 3M = 3 times monthly)

What types of foods do you crave?

Salty Chocolate Sweets Breads

What are your favorite foods?

On a daily basis, how much energy do you have? (1 = lowest energy; 10 = highest energy)

How many surgeries have you had, what type and when?

How much TV do you watch on a daily basis? Weekly basis?

How many hours of spiritual enrichment do you get each week? (Bible, prayer, church, etc)

How many hours per week do you spend with family/friends?

How many hours of sleep do you typically get each night?

How many hours of sleep do you believe you need each night?

Would you like to sign up for our natural health blog mailing list?

Who referred you for your appointment today?

For any symptom(s) selected, please elaborate.

I understand that I am here to learn about nutrition and better health practices. I may be offered information about food supplements and herbs as a guide to general good health. I also understand that this is a personal ministry and spiritual counseling.

I fully understand that those who counsel me are not medical doctors and I am not here for medical diagnostic purposes or treatment procedures. I am not on this visit or any subsequent visit as an agent for federal, state, or local agencies nor am I on a mission of entrapment or investigation.

The services performed here are at all times restricted to consultation on nutritional matters intended for the maintenance of the best possible state of natural health and do not involve the diagnosing, treatment, or prescribing of remedies for disease.

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