ReVitalizeLife - Dr Elvira Gesummaria
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NATUROPATHIC MEDICINE
Adult Intake form

​new adult patients intake form​​
​

For all new patients, please fill out this form to the best of your ability. It will help to assess your present health and will assist in facilitating the healing process.

    intake form - adults



    Emergency Contact:

    How did you hear about our clinic?


    Names of other health care practitioners (medical doctor, chiropractor, specialist, physiotherapist, etc.) you are seeing:

    CHIEF HEALTH CONCERNS
    ​

    Please describe your primary health concern below:


    MEDICAL HISTORY
    ​​

    List all names of prescribed medication currently being taken. Include dosage, frequency, how long you have been taking it, and any adverse reactions/allergies to medications:

    Indicate the vaccinations have you received: 
    ​

    PREVIOUS HEALTH HISTORY/FAMILY HISTORY

    Please indicate any significant medical conditions present in your family - alive or deceased (e.g. heart disease, stroke, mental illness, thyroid conditions, cancer, diabetes, etc.) and specify which member of your family you are referring to: 

    LIFESTYLE

    Please list what you have had to drink and eat in the past 24 hours:

    If you are a female are you:

    ENVIRONMENT 


    REVIEW OF SYSTEMS 

    Please select ‘Yes, No or Past’ if you are currently experiencing the condition. Write comments as necessary in the space provided.

    skin


    HEAD


    eyes


    ears


    nose


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© COPYRIGHT 2021. ELVIRA GESUMMARIA, REVITALIZELIFE. ALL RIGHTS RESERVED.
  • Home
  • About
  • Services
  • Virtual Yoga & Healing Classes
  • Workshops
  • Gemstone Shop
  • Pricing
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