ReVitalizeLife Naturopath Forms Bookings

Name *

Practitioner: *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Name *

Practitioner: *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Name *

Practitioner: *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

CHIEF HEALTH CONCERNS

Please describe your primary health concern below:

Comment *

LIST OTHER HEALTH CONCERNS IN ORDER OF IMPORTANCE TO YOU BELOW: *

MEDICAL HISTORY

Describe your present general state of health: *

Please indicate any serious conditions, illnesses, infections, injuries, and any surgeries or hospitalizations (provide approximate dates): *

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:

Taken Since (How Long) *

Frequency (times/day) *

Taken Since (How Long) *

Frequency (times/day) *

Taken Since (How Long) *

Frequency (times/day) *

Adverse Reactions/ Allergies (describe) *

How many times have you been treated with antibiotics? *

Number of steroid type drugs used during the last year: *

List all over the counter medication that you take (e.g. Aspirin, Tylenol, Tums, etc.). Include dosage and frequency and any adverse reactions/allergies to medications: *

List all vitamins, minerals, botanical (herbal) medicines, Asian medicines (Chinese Patent drugs), or homeopathic remedies that you are currently taking. Indicate daily dosage: *

Do you use any recreational drugs? Y/N (If yes, indicate what type and frequency of usage): *

Do you have regular screening tests done by another doctor? Y/N (blood tests, Pap smear, prostate exam, etc.) *

YES NO

When was your last physical exam? *

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

Do you have any dietary restrictions (religious, vegetarian/vegan, etc.)? *

YES NO

If yes, please describe *

Number of glasses of water or natural fruit juice per day: *

Percentage of fat in your diet (i.e. processed/junk foods, fried, dairy, meat fats): *

Number of sugar products/day on average (i.e. soft drinks, ice cream, cookie, sugar in coffee etc.) *

Do you drink alcohol? *

YES NO

(If yes, indicate what type of alcohol and how many glasses per week): *

Do you smoke? *

YES NO

(If yes, indicate for how long, and how many cigarettes/cigars per day): *

Do you drink caffeinated beverages? *

YES NO

(If yes, indicate what type and how much per day): *

On average, how many hours of sleep do you get per night? *

On average, how many hours do you work each day? *

What level of personal stress have you been experiencing within the last 2 weeks? *

0 1 2 (minimal) 3 4 5 (average) 6 7 8 (considerable) 9 10 (unbearable)

Do you exercise? *

YES NO

(Indicate what type of exercise, how long, how often): *

If you desire to lose weight, how much would you like to lose? *

Are you sexually active? *

YES NO

Method of contraception: *

If you are a female are you:

Pregnant? *

YES NO

Lactating? *

YES NO

How much do you agree with this statement: “I am responsible for my body” (1 being least, 10 being most): *

ENVIRONMENT

Number of extreme toxic exposures/year (includes radiation, insecticides, chemicals) *

Are you regularly exposed to toxins or other hazards (work, home, hobbies, etc.)? Please describe: *

Areyouexposedtosignificanttobaccosmoke(work,home,etc.)? *

YES NO

Are you frequently exposed to animals (work, pets, etc.)? *

YES NO

(Indicate what type): *

How is your home heated? *

How would you describe the emotional climate of your home? *

How stressful is your work, or other aspects of your life? How well do you handle these stresses? *

other *

Is there anything that you feel is important that has not been covered? *

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

Itching *

Select One *

Comments *

HEAD

Select One *

Untitled *

eyes

Select One *

Untitled *

ears

Select One *

Untitled *

NATUROPATHIC MEDICINE
Adult Intake form

new adult patients intake form

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:

PREVIOUS HEALTH HISTORY/FAMILY HISTORY

LIFESTYLE

ENVIRONMENT

REVIEW OF SYSTEMS

skin

HEAD

eyes

ears

nose

Services

Company

Support

NATUROPATHIC MEDICINEAdult Intake form

​new adult patients intake form​​​

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:

PREVIOUS HEALTH HISTORY/FAMILY HISTORY

LIFESTYLE

ENVIRONMENT

REVIEW OF SYSTEMS

skin

HEAD

eyes

ears

nose

Services

Company

Support

For Spiritual and Health Advice, Yoga, and Updates:

NATUROPATHIC MEDICINE
Adult Intake form

new adult patients intake form

CHIEF HEALTH CONCERNS

Please describe your primary health concern below:

MEDICAL HISTORY