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Date of Birth (mm/dd/yyyy)
Number of children
How did you hear about our practice?
Please list your health concerns in order of importance
List all vitamins/minerals/herbal supplements you are currently taking
List all prescription and non-prescription medications you are currently taking
List any major illnesses, injuries and/or surgeries that you have had and when
Do you have any hypersensitivity or allergy to any drugs?
Do you have any food intolerances or allergies?
Do you have any environmental sensitivities?
Weight 1 year ago (lbs)
Please put an "L" for living and "D" for deceased, and present age or age at time of death. Indicate if the family member suffered from any disease or conditions such as cancer, high blood pressure, heart attack, stroke or diabetes.
Do you have any amalgam fillings? If yes, how many?
Do you have any root canals? If yes, how many?
Main interests and hobbies
Do you exercise? If yes, how often?
Do you smoke? If yes, for how long and how many per day?
Do you use recreational drugs? If yes, which ones?
Rate your energy1 (low)2345678910 (high)
Rate your stress1 (low)2345678910 (high)
Do you have difficulty falling asleep?YesNo
How many hours of sleep do you get on average?
Do you wake up during the night? If yes, how often?
Do you feel refreshed in the morning?YesNo
How frequently do you move your bowels?
Loose stools?Diarrhea?Hard stools?Difficulty passing?Blood in stools?Undigested foods in stools?Mucous in stools?Gas?Bloating?Heartburn/Reflux?Abdominal Pain?
Do you have your gallbladder?YesNo
Do you have your appendix?YesNo
Age of your first menses?
How may days of menses?
How long is your cycle?
Heavy flowLight flowClottingBleeding between periods
Pain or crampingMood SwingsBloatingHeadachesBreast TendernessCravings
Are you sexually active?YesNo
Form of contraception used
Do you get yeast infections?YesNo
When was your last pap test?
History of abnormal pap?YesNo
Are you menopausal?YesNo
If yes, age of last menses
Hot flashesDisrupted sleepPoor memoryChanges in moodLow libidoPain during intercourseVaginal itchingVaginal dryness
ImpotenceSexually transmitted diseaseSores on genitalsDischargeTesticular MassTesticular PainInfertility/Low sperm countHerniaProstate condition
Are you currently sexually active?YesNo
Current form of contraception?
Please check any of the following that apply to you as well as those you have experienced in the past.
FatigueChange in appetiteChange in thirstCravingsWeight gainWeight lossPoor sleepChills or feverNight sweatsSweat easilyAllergiesCancerDiabetes
DrynessRashItchingEczemaPsoriasisAcneRecent molesHives/allergic reactionsLoss of hairThinning hairDandruffOther skin problem(s)
Eye painEye strainBlurry visionImpaired visionCataractsEar achesEar infectionsRinging in earsVertigo or dizzinessSinus infectionsNasal obstructionPost nasal dripNosebleedsLoss of smell/tasteTonsillitisSores in mouthMercury fillingsJaw pain or clicksRecurrent sore throatEnlarged glandsEnlarged thyroidFacial pain/ticsHeadaches
Chest painPalpitationsHigh blood pressureLow blood pressureHeart attackCongestive heart failureIrregular heartbeatPacemakerArtificial heart valveFaintingVaricose veinsDeep leg painCold hands or feetAnemiaEasy Bruising
Difficulty breathingChronic coughBronchitisEmphysemaAsthmaWheezingCoughing bloodPhlegm in throat
Neck painBack painArthritisBursitisJoint pain or stiffnessArtificial jointMuscle painMuscle weakness
NauseaVomitingVomiting bloodReflux or heartburnConstant hungerUlcerGall stonesConstipationDiarrheaChronic laxative useRectal burning/painHemorrhoidsBlood in stool
AnxietyDepressionIrritabilityEmotional problemsLoss of balancePoor memoryDizzinessSeizures/EpilepsyConcussionLack of coordinationExtremity numbnessExtremity tinglingParalysis
Frequent urinationUrgency to urinateIncontinencePain on urinationWake at night to urinateUrinary tract infectionBlood in urineKidney stones
I attest that the information provided is true and accurate to the best of my knowledge.
Signature (Full Name)
Naturopathic Doctors minimize the risk of harmful side effects, by supporting the body's own capacity to heal and by using the least invasive procedures for diagnosis and treatment whenever possible. However, even the gentlest therapies have potential for complications. Some therapies must be used with caution in certain diseases such as diabetes, heart, liver or kidney disease, or in specific patient populations such as pregnant or lactating women, very young children, or patients taking multiple medications. It is very important that you inform your Naturopathic doctor immediately of:
There are some slight health risks to treatment by Naturopathic Medicine. These include but are not limited to:
I understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others unless so directed by myself or when law requires it. I understand that I may look at my medical record at anytime and can request a copy of it or have a report drawn up by paying the appropriate fee. I understand that information from my medical record may be analyzed for research purposes and that my identity will be protected and kept confidential.
I understand that my Naturopathic Doctor will answer any questions that I have to the best of his/her ability. I understand that the results are not guaranteed. I do not expect the Naturopathic Doctor to be able to anticipate and explain all risks and complications. I will rely on the Naturopathic Doctor to exercise judgement during the course of the procedure which they feel at that time is in my best interests, based on the facts then known.
I intend this consent form to cover the entire course of treatment for my present condition. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time.
If I am unable to make my appointment I must provide advance notification within 48 hours in which case no charge will be applied.
THIS IS TO ACKNOWLEDGE that I have been informed and I understand that:
I DECLARE that I have received a full and complete explanation of the treatment or services that I may receive and hereby authorize and consent to treatment.
I AGREE to pay my full account at the time of each visit or treatment, including fees for services, cost of supplements and remedies, as well as other applicable fees. I understand that there is a fee for completing insurance forms, letter writing, telephone consultations greater than 10 minutes and emails that take greater than 10 minutes to answer. Notice of 48 hours is required for appointment cancellation, otherwise you will be charged an administrative fee of $35.00.
Patient's Full Name
Date of Consent (mm/dd/yyyy)
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