Intake Form

Printable Form:    Web Intake Form (pdf)

If you are a new patient we ask that you fill out an intake form.  This form is for all patients aged 6 years and older.  Thank you in advance!

Today's date:

Your name:*

First

Last

Preferred pronouns:

Date of Birth:*

01020304050607080910111213141516171819202122232425262728293031day

 / 

JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth

 / 

201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901year

Phone:*

Area Code

 - 

Phone Number

E-mail:*

Address (House number, street, city, postal code)

PHN - Personal Health Number*

Main reason(s) for seeking Naturopathic medical care. Please indicate order of importance and when symptoms first appeared.*

Medical Doctor's name:

Are you familiar with naturopathic medicine?

How did you hear about our Clinic?

Please list medication/drugs you are currently taking:

Please list all supplements you are currently taking:

Do you wear a medic alert bracelet?

yes

If so, for which condition?

Do you have a pacemaker?

yes

Do you have any medication/drug related allergies?

yes

If so, please list medication/drugs:

Do you have any food/environmental allergies or sensitivities?

yes

If so, please list food/environmental:

For Women: Date of last PAP test?

If over 50, date of last mammogram?

Have you been diagnosed with any medical conditions? Please list:

Are there any conditions after which you have never been totally well since, or which have been more serious than usual?

Please list any medical conditions in your FAMILY that you are aware of:

What are your short-term health goals?

What are your long-term health goals?

Extra Notes:

Word Verification:

SubmitReset

IMPORTANT: Please read the information below before you press ‘Submit’

After you submit your form, a confirmation message will appear at the top of the screen that reads, “SUCCESS! We have received your intake form. Thank you.” A confirmation email will also be sent to you, which contains all the information you input into the form.  If you do not receive these confirmations, it means that your submission was not processed and will need to be entered again.