Health History And Goals
Full Name
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First Name
Last Name
Gender
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Male
Female
Age
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Primary Phone Number
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Area Code
Phone Number
Secondary Phone Number
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Area Code
Phone Number
E-mail (will be used to send receipts, monthly newsletters and events)
Occupation
Lifestyle and Medical History
Current Weight
Height
Personal Medical History. Please check any diseases or conditions that you have had in the past or currently.
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Heart Disease
High Blood Pressure
High Cholesterol
Stroke
Diabetes
Thyroid Disease
Cancer
Depression
Anxiety
Lung Disease
Blood Transfusion
Asthma
Migraines
Kidney Failure
Sleep Disorder
Blood Clots
Hepatitis
Head Trauma
Reflux
Epilepsy
Substance Abuse
Psychiatric Hospitalization
Neck Trauma
Fibromyalgia
Liver Disease
ADD/ADHD
HIV/AIDS
None
Other
Surgical History. Please check any surgeries you have had.
Heart
GI (Bariatric)
Gall Bladder
Cataract
Cancer
Breast Lump
Bladder
Tonsils
Brain
Complete Hysterectomy
Partial Hysterectomy
Fibroids
None
Other
Are you currently taking any medications? Which ones?
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Are you currently taking any vitamins and/or herbs? Which ones?
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Please list any allergies (food, drug, environmental). Please write 'NONE' if you have none.
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1. What are your main health concerns? Please list your top 5 below.
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2.
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3.
4.
5.
What Are Your Goals For Your Health?
Please read carefully and enter your initials at the bottom.
INFORMED CONSENT: A Naturopathic Doctor (ND) is trained as a primary care provider and is a board-certified physician in states where licensure is applicable. Naturopathic doctors concentrate on whole-patient wellness. Recommendations are specific to each patient and emphasize prevention and self-care. Naturopathic Doctors focus on the underlying cause of the patient’s condition rather than focusing solely on symptoms.The recommendations you will receive in this personalized Roadmap may include options for you to get one on one guidance and support through one of our Natural Health or Lifestyle Coaching programs.
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The information provided by the Naturopathic Doctor is for educational purposes only and is not intended as a substitute for advice from your personal primary care physician. You should not use the information provided for diagnosis or treatment of any health problem. You should consult with a primary care provider before starting any diet, exercise or supplementation program, before taking any drugs, or if you have or suspect you might have an undiagnosed condition. You should not stop taking any medication without first consulting your prescriber. I understand the above Informed Consent. (Initial Below)
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