Initial Intake Form

Dear Friend, 

Consistent with our firm commitment to practice whole-person, individualized care, we would like to get to know you better.  Below is our initial intake form for all new patients and is our way of really coming to understand you as a whole person and thus having the basis to adequately address your health concerns. Please complete the form to the best of your knowledge. Also, honesty is extremely important as we are not here to judge but rather to explore the best approach to take in your care. We would like to thank you very much in advance for taking time to complete this form as it is very comprehensive in nature. 

 

Name *
Name
Address *
Address
EMERGENCY CONTACT
Name 1
Name 1
Phone
Phone
OTHER PROVIDERS
Please list other health care providers you currently work with (name and profession will suffice).
Does your extended health care plan cover naturopathic medicine?
MEDICAL CONCERN
If there is other information regarding the health concern that was missed on the initial patient request form that you feel is important, please let us know below.
Please list past medical conditions and hospitalizations
Please list medical conditions in the family including: siblings, parents, and grandparents.
Please list all allergies past and present.
Please include dosages if possible, and when you started taking.
REVIEW OF SYSTEMS
Please list any symptoms or health concerns that have currently experience whether they seem related or not to your present chief health concern(s).
Please select usual appearance
Do you get colds, runny noses, and flus easily?
Usual appearance of urine
Menstruation
How long is your typical cycle?
Description of menstrual flow (Color, volume, etc).
Are your cycles regular?
DIET & NUTRITION
My typical times for breakfast, lunch and dinner are?
When I eat between meals, it is usually at these times and what I usually eat is/are:
The types of oil I use *
I use oil for *
PHYSICAL ACTIVITY & EXERCISE
How many days a week are you doing structured physical activity?
Please share with us what types of exercise activities you are currently engaged in.
Please list any activities you would like to explore and also activities you absolutely dislike doing.
Equipment available at home are: *
List if any.
SLEEP & SUNLIGHT
MOOD & EMOTIONS
Worry *
Over the last 2 weeks, have you experienced any of the following symptoms?
Mood *
Over the last 2 weeks, have you experienced any of the following problems?
1 = no stress 10 = extremely high amounts of stress
1 = no energy 10 = very high levels of energy
SPIRITUALITY
My spiritual practices are *
George Cho