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  • Intake Form & Waiver for Services

    Your answers are strictly confidential and will allow us to have a better understanding of who you are and your main goals and health concerns.
  • Date of birth*
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  • Contact Information

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  • In case of emergency...
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  • Naturopathic Visit

  • Have you ever seen a Naturopathic Doctor before?

  • Health Information and History

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  • Do you see any other healthcare providers? If so, please list their information below.

  • If you have a current health condition, or have been diagnosed with one in the past, please list below (eg. diabetes, cancer, IBS etc...)

  • Any history of surgery or hospitalizations?

  • Please indicate if you have had any of the following concerns in the past year, or of significance in the past.

  • Muskuloskeletal
  • Skin
  • Nose and Sinus
  • Mouth and Throat
  • Cardiovascular System
  • Respiratory
  • Neurological
  • Endocrine System
  • Digestive System
  • Urinary System
  • Immune System
  • Mental/Emotional Health

  • Please indicate if any of your family members currently have a health condition, or have had one in the past


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  • Health Assessment and Medical Information

  • Has your weight ever fluctuated by more than 10lbs in a short period of time?
  • Are you taking any medications? Include any prescription drugs, over-the-counter medication, birth control pill etc..
  • Are you taking any supplements, minerals/vitamins, herbs or other natural health care products?
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  • Dietary and Lifestyle Habits

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  • Do you have any known (or suspected) food allergies or intolerances?
  • Do you have any dietary restrictions? (eg. religious, vegan/vegetarian)

  • Please describe a typical day's diet

  • Do you experience any of the following (check all that apply)
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  • Do you consume alcohol?
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  • Do you smoke tobacco?
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  • Are you regularly exposed to second hand smoke?
  • Do you use recreational drugs?

  • Home Environment

  • Do you live close to any of the following?
  • Have you done any recent renovations to your home?
  • Do you have any household pets?

  • Sleep, Energy and Stress Levels

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  • On average, how many hours of sleep do you get?
  • Do you have difficulty falling asleep?
  • Do you have difficulty staying asleep?
  • Do you nap during the day?
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  • Women's Health

  • Date of last menstrual period
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  • Are you currently pregnant?
  • Are you currently breastfeeding?
  • Are you trying to become pregnant?
  • Are you currently sexually active?
  • Date of Last Pap Test
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  • Was it normal?
  • Do you perform monthly self breast exams?
  • Have you ever had a mammogram?
  • Date of last mammogram
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  • Men's Health

  • Are you sexually active?
  • Do you experience painful or difficult urination?

  • Please quickly rate your level of satisfaction with the following areas of your life.

    (1 star = not satisfied, 5 star = very satisfied)

  • Treatment Waiver

  • I, the undersigned person(s), do agree and understand that the practioners of Rivers Edge Natural Health are NOT medical doctors, chiropractors, registered nurses, licensed practical nurses, licensed physical therapist/physio-therapists or licensed counselors.  I understand and agree that they only claim to be, respectfully, a Doctor of Naturopathic Medicine, Certified Natural Health Practioners (CNHP's), a DieteticTechnician Registered (DTR), a Christian Family Preservation Child/Family Advocate and Ordained Ministers.

     

    I affirm that I have come to this agency to avail myself of the respected servcies offered and have not, nor will I ask these practitioners to do anything illegal, nor anything that is against the practioner's personal or professional values and/or ethics.  Further, I release them from any and all liability arising out of claims or matters that relate, in whole or in part, to my sessions with Rivers Edge Practioners.

  • Today's Date
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  • Thanks for taking the time to complete this intake form and We look forward to meeting you!

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