FLOURISH: New Patient Intake

New Patient Intake
Please fill in the form below. All questions are to help us give you the best care possible. All of your answers will be kept completely confidential and secure.
Legal Name*
First NameMiddle NameLast Name
Preferred Name
Best E-mail*
Preferred Pronoun*
Sex at Birth*
Gender Identity*
Sexual Orientation*
Date of Birth*
MonthDayYear
Height (inches)
Weight (pounds)
*We do not use weight as an indicator of health. Please decline to answer per your preference.
Phone Number:*
Area CodePhone Number
Is it okay to leave a detailed message at this number?*
YesNo
Address:*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
Is it okay to send marked mail to the address?*
YesNo
How did you hear about FLOURISH?*
In case of emergency...
Emergency Contact:*
First NameLast Name
Phone Number*
Area CodePhone Number
Relationship
Allergies to medications:*
Other allergies/sensitivities: *
Please list any medications you are currently taking: *
Include medication name, dosage, how often taken, reason for taking, and how long it's been taken. If more than one, separate with commas. If it's easier, you may bring all of your bottles to your appointment.
Please list any herbs/supplements you are currently taking: *
Include supplement name, dosage, how often taking, reason for taking, and how long it's been taken. If more than one, separate with commas. If it's easier, you may bring all of your bottles to your appointment.

What problems, symptoms, or concerns prompted you to book this session: *
How much are these things affecting your life? *
What medications, natural therapies, or other treatments have you tried prior to this? *
What are your goals for your life? How do you wish your health was supporting these goals? What obstacles are standing in your way?*

Medical History
Family History
Please list any signficant illnesses (or cause of death) you could inherit from:
Mother*
Father*
Maternal Grandmother*
Maternal Grandfather*
Paternal Grandmother*
Paternal Grandfather*
Siblings*
Children*
Other*

New Patient Intake