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54 Merrimon Avenue
Asheville, NC 28801

 

(828) 254-3004
 AshevilleNaturalHealth.com

 

New Patient Information

Name
Address
City

Zip Code  

State
Phone
Cell Phone
E-mail

 
Single  Married Separated  Divorced
               
Date of Birth
Number of Children:
Occupation:
Referred By:

Major complaints in order of importance to you
Complaint Since Causes

Treatment Since Results

Which of the following conditions have you had?
Abscesses   Depression   Headaches   Pelvic Sties
Acne Diabetes Heart Disease Inflammatory disease Stroke
Alcoholism Dizziness Hepatitis Pleurisy Sunstroke
Allergies Digestive Problems Infertility Pneumonia Thyroid condition  
Anemia Ear infections Ingrown toenails Psoriasis Tonsillitis
Asthma Endometriosis Joint pain Respiratory disease Tropical disease
Athlete's foot Fibromyalgia Kidney disease Root canal Tuberculosis
Back pain Flu Menstrual problems Scarlet fever Uterine fibroid
Cancer Gallstones Miscarriage Seizures Vaginitis
Canker sores Genital herpes Mononucleosis Septicemia Venereal warts
Chicken pox Goiter Mood problems Sexual abuse Vertigo
Cold sores Gout Mumps Sinusitis Warts
Fatigue Hay fever Parasites Skin disease Whooping cough
 

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54 Merrimon Avenue
Asheville, NC 28801

 

(828) 254-3004
 AshevilleNaturalHealth.com

 

New Patient Information

What operations have you had?
Operation When Complications

What major injuries have you had?
Injury When Long term effects
Age of 1st menses:
Number of pregnancies
Miscarriage/abortion:
Any adverse effects from vaccinations?
Condition?
Have you ever taken antibiotics for a prolonged period of time?
When was your last physical exam?
How many pounds?
Have you lost any weight lately?
Frequency?
What exercise do you do?
Tobacco
How much of the following are you using:
Coffee
Tea
Alcohol

Which of the following have affected your relatives?
Alcoholism      Depression    Heart Disease      Pelvic
Allergies Diabetes  Mental Illness Skin disease
Arthritis Epilepsy Hepatitis Syphilis
Asthma Gonorrhea Paralysis Tuberculosis
Cancer Gout Pneumonia Psoriasis
Relative Age if alive Age at death Ailments
Mother
Father
Bothers
Sisters
Children

Maternal
g-mother
g-father
aunts/uncles

Paternal
g-mother
g-father
aunts/uncles

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54 Merrimon Avenue
Asheville, NC 28801

 

(828) 254-3004
 AshevilleNaturalHealth.com

 

New Patient Information

Are you currently under the care of another health professional?
Specialty For what conditions Treatment

Have you been treated with homeopathy before?
Physician For what conditions When
Remedy(ies) received
How did you hear about us?

Payment policy and scope of services

I acknowledge that payment is due at the end of the visit and that these payments are not reimbursable by any insurance provider in the state of North Carolina. Phone consultants that serve as follow up or acute visits will be billed as such.

I understand that the doctor will advise me on how to improve my general health using nutrition, nutritional supplements, herbs and homeopathic preparations. I also understand that the doctors at Asheville Natural Health and Homeopathy are licensable in all states licensing Naturopathic Physicians. However, the doctors are not currently licensed to diagnose or treat disease in the state of North Carolina. The advice provided by the doctors is intended to complement, not replace, any treatment prescribed by a licensed physician.

Medical interns and professionals

Our doctors do on occasion allow interns and other physicians to observe their practices for educational purposes. We respect that not every patient is comfortable with this and ask that you let us know of your preference:
I do not wish to have interns or other physicians present during my visits.
I agree to have interns or other physicians present during my visits.
 

By submitting this form, you agree to the above terms and conditions