Naturopathic Intake Form
Name
*
First Name
Last Name
Address
*
Address
Address Line 2
City
Province
Postal Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Family Doctor
Name
Phone
Emergency Contact
*
Name
Phone
Height (ft)
*
Weight (lbs)
*
Blood Type
Are you currently seeing any other health care providers? (i.e. Other Naturopathic Doctors, Chiropractors, Acupuncturist, Massage Therapists, etc.) If so, please list here:
How did you hear about the IV?
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Please Select
IV Website
Instagram
Facebook
Radio
Google
Family/Friend
Special Event
Other (Please specify...)
Other
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How did you hear about your Practitioner?
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Please Select
Website
Instagram
Facebook
Family/Friend
Referral (Please specify...)
Referral
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Would you like to receive our newsletter for the latest news and features?
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Yes
No
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Health Information
List your health concerns (physical, emotional, or psychological) in order of importance to you, and the date your symptoms began:
Rows
Health Concern
Date
1
2
3
What do you believe is causing your most important health concern?
What treatments have you tried for your health concerns and did they help?
Allergies and Sensitivities
List all allergies to medications, environment, and food:
Supplements and Medications
List all that you are currently taking and for how long:
Medical History
List any condition that you have been diagnosed with and date of diagnosis:
List any diagnostic tests performed (blood sugar test, cholesterol, food sensitivity, etc.):
Family History
Indicate whether any family members have had any of the following:
Rows
Yes
Relation to You
Alcoholism
1
Allergies
2
Alzheimer's Disease
3
Arthritis
4
Asthma
5
Cancer (indicate type)
6
Depression
7
Diabetes
8
Drug Abuse
9
Heart Disease
10
High Blood Pressure
11
Kidney Disease
12
Osteoporosis
13
Stroke
14
Other Illnesses
15
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Digestive Health
Do you experience any of the following regarding your bowel movements?
Loose stools
Hard stools
Thin stools
Constipation
Blood in stools
Dark stools
Undigested food in stools
Mucous in stools
Do you experience any of the following digestive symptoms?
Bloating
Flatulence
Belching
Heartburn/reflux
Excess fullness after meals
Abdominal cramping/pain
Nausea
Vomiting
Haemorrhoids
Anal fissures
History of food poisoning/parasites
Do you currently or have you experienced any of the following?
Frequent dieting
Binge eating
Poor appetite
Always hungry
Can’t gain weight
Can’t lose weight
Emotional eater
History of bulimia/anorexia
How many cups of water do you drink per day? (including decaffeinated teas)
1-3 cups
4-7 cups
8 or more
Nutritional Health
Are you sensitive to any of the following foods?
Dairy
Sugar
Alcohol
Red meats
Greasy foods
Garlic/onions
Carbohydrates (breads, pastas, pastries)
Beans (chickpeas, lentils, etc.)
Cruciferous vegetables (broccoli, cauliflower, asparagus etc.)
Do you crave any of the following foods?
Sugar
Chocolate
Carbohydrates
Salt
Other
Immune System Health
Vaginal or C-Section birth?
Vaginal
C-Section
How many rounds of antibiotics have you been on before puberty?
How many rounds of antibiotics have you been on in the last 5 years?
Do you experience any of the following?
Frequent cold/flues
History of chronic viral infection (mono, herpes, shingles, hepatitis, HIV etc.)
Urinary tract infections
Sexually transmitted infections
Yeast infection (toenail fungus/athlete’s foot, vaginal/jock itch, tinea, etc.)
Other infections (sinus, ear, lung, skin, bladder, kidney)
Slow wound healing
Strong body odour
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Nose / Throat / Respiratory Health
Do you experience any of the following?
Pneumonia/bronchitis
Asthma
Nasal congestion/phlegm
Snoring/sleep apnea
Bad breath/bad taste in mouth
Enlarged lymph nodes
Cold sores
Canker sores
Receding gums
Skin / Hair / Nails
Do you experience any of the following?
Dandruff
Itchy ears
Dry skin
Oily skin
Cellulite
Acne
Eczema
Psoriasis
Hives
Bump on back of arms
White coat on tongue
Lack of sweating
Sweating easily
Dark circles under eyes
Soft or brittle nails
Ridging or spots on nails
Hair loss or breaking
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Should be Empty: