New Patient Form

General Information

Name*
First Last
Parent/Guardian
Street Address
City, State, Zip Code
Primary Phone
Alternate Phone
Email
Date of Birth
Sex
- male
- female
Relationship Status
- N/A (child)
- single
- married
- partnered
- separated
- divorced
- widowed
Children (names/ages)
Spouse/Partner's Name
Occupation
How did you hear about us?

Major Health Concerns

Please click on the headings below to tell us about your major health concerns, in order of importance to you.

health concern #1

What is it?
Since when have you had this concern?
What do you believe caused it?
Have you had treatment for this concern? When? With what results?

health concern #2

What is it?
Since when have you had this concern?
What do you believe caused it?
Have you had treatment for this concern? When? With what results?

health concern #3

What is it?
Since when have you had this concern?
What do you believe caused it?
Have you had treatment for this concern? When? With what results?

health concern #4

What is it?
Since when have you had this concern?
What do you believe caused it?
Have you had treatment for this concern? When? With what results?

Current Medications/Supplements

Click on the headings below to tell us about your current medications and supplements.

medication/supplement #1

What is it?
Dose and Frequency
How long have you taken it?
Adverse effects, if any

medication/supplement #2

What is it?
Dose and Frequency
How long have you taken it?
Adverse effects, if any

medication/supplement #3

What is it?
Dose and Frequency
How long have you taken it?
Adverse effects, if any

medication/supplement #4

What is it?
Dose and Frequency
How long have you taken it?
Adverse effects, if any

medication/supplement #5

What is it?
Dose and Frequency
How long have you taken it?
Adverse effects, if any

Operations

Click on the headings below to tell us about your operations.

operation #1

What was it?
When was it?
Were there any complications?

operation #2

What was it?
When was it?
Were there any complications?

operation #3

What was it?
When was it?
Were there any complications?

Major Injuries

Click on the headings below to tell us about your injuries.

injury #1

What was it?
When was it?
Any long-term effects?

injury #2

What was it?
When was it?
Any long-term effects?

injury #3

What was it?
When was it?
Any long-term effects?

Current Healthcare Professionals

Are you currently under the care of another healthcare professional? Click below to tell us.

provider #1

Name and specialty
For what conditions?
Treatment

provider #2

Name and specialty
For what conditions?
Treatment

provider #3

Name and specialty
For what conditions?
Treatment

provider #4

Name and specialty
For what conditions?
Treatment

When was your last physical exam?
Physician's name

Previous Naturopathy/Homeopathy

Have you been treated by a naturopath or homeopath before? Click on the headings below to tell us about your experience.

practitioner #1

Practitioner's name
For what conditions?
When?
Treatment and remedies

practitioner #2

Practitioner's name
For what conditions?
When?
Treatment and remedies

practitioner #3

Practitioner's name
For what conditions?
When?
Treatment and remedies

Lifestyle/Miscellaneous

Have you had any infectious disease from which you have never fully recovered?
Any adverse effects from vaccinations?
Have you taken antibiotics for a prolonged period of time?
For what condition?
Have you gained or lost any weight lately? If so, how many pounds?
What is your ideal weight?
How tall are you?
What exercise do you do and how often?
Do you use any of the following? If so, how often?
Tobacco
Alcohol
Recreational Drugs
What do you drink during the day and how much? (Coffee, tea, soda, water, juice, etc.)
What special diet do you follow, if any? (Vegetarian, vegan, food allergy, Atkins, etc.)

New Patient Information

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