Patient Intake Form

The Naturally Good Health Clinic

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.

Patient Intake

Patient Intake

Address
City
Province
Postal Code

Emergency Contact

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

How many glasses of water do you drink per day?

How many glasses do you drink per day of the following?

How many cups/day do you drink of the following?

Please complete all that are applicable to you and your family and note who:

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

Contact Us

Ask a question or inquire about booking an appointment below.

403-289-0989

1904-B 20 Ave NW Calgary, Alberta T2M 1H5

info@naturallygoodhealth.com