Online Intake Form

Naturopathic Intake Form

Health issues are influenced by a number of factors, including dietary, lifestyle, emotional, and social factors. The following questions are designed to improve my understanding of you and your health conditions. By carefully filling out this form as completely as possible, you will improve the efficiency of our scheduled appointment time by helping me to more quickly and accurately determine the root causes of your health concerns and to formulate the most suitable treatment plan. Please fill out and send this form a minimum of 48 hours prior to your scheduled appointment.

This form is encrypted and its standards are verified by a third party (TRUSTe). Any information sent can be viewed only by myself and will be kept strictly confidential.

Address

Address *

City *

Province *

Postal Code *

Contact Information

E-mail Address

Can we contact you via E-mail to remind you about appointments, send surveys, or send our newsletter? YesNo

Phone number (Primary) *

Phone Number (Secondary)

May we leave a message relating to your visits? YesNo

Emergency Contact Name *

Emergency Contact Number *

Health History

Please list your health concerns, in order of importance to you *

Please list any past serious health problems, surgeries, or hospitalizations and their approximate dates

What is your height?

What is your current weight?

Medications and Supplements

Please list your current medications and their dosages

Please list the medications you have taken in the past

When is the last time you were treated with antibiotics? What was the reason?

Please list your current natural supplements and their dosages (herbs, vitamins, homeopathics, etc)

Diet and Lifestyle

Please describe your typical daily breakfast, lunch, dinner and snacks and approximate time you consume them *

Please list all beverages consumed during the day (water, juice, coffee, tea, etc) and their quantities *

How many hours do you sleep each night? *

Do you feel rested when you wake? YesNo

Do you smoke? * YesNoIn the past

If yes or in the past, how much per day?

How many alcoholic drinks do you consume during a typical week?

Do you use recreational drugs? YesNo

If yes, what type and how often?

Do you experience frequent high stress? YesNo

If yes, what area(s) of your life are the most stressful?

Are you able to cope well with this stress, or do you frequently feel overwhelmed?

Describe which forms of exercise, if any, you participate in, and how many times per week

How many close friends are in your social network?

Health Goals

What are your health goals? *

What are your expectations in working with me during the course of your treatment?

What is your level of commitment in following my recommendations during our time working together, from 1 to 10? *

Please fill this form out before coming to your appointment

Online Intake Form

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