Naturopathic Patient Intake Form
Our professional association requires us to maintain contact information for our patient records. No information will be provided to any other individual or group without your express permission. E-mail will only be used by our office to inform you of our office events and to distribute our newsletter 4-6 times a year; it will not be distributed for any other use.
Instructions for use: Items marked with a " * " are required. You will not be able to submit the form unless ALL required fields have been completed. If you would prefer, you may print a copy of these forms and bring them with you to your appointment. Please do not print this page, you can access a printable version here.
Please list all medications you have taken, Pharmaceutical, Herbal, Vitamins and Supplements, including dosages.
Please list any allergies you have and the reaction that occurs.
ie: surgery: Jan 1, 2001
Wellness is a balance of many factors. Using the scales below, indicate your level of satisfaction in each area as it relates to you, 10 being the most satisfied.
Context of Care Overview