Name
*
First Name
Last Name
Date of Birth
MM
DD
YYYY
Age
*
Sex
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email address
*
Phone number
(###)
###
####
Are you currently enrolled in any of the following social assistance programs?
*
Those enrolled in government social assistance programs are eligible for discounted rates.
Are you a member of any of the following organizations or programs?
Members are eligible for discounts.
Name
*
First Name
Last Name
Phone
*
(###)
###
####
Insurance coverage
*
Does your extended health care plan cover naturopathic medicine?
Chief Concern(s)
*
Very briefly list / describe chief health concerns
Personal medical history
*
Please list past medical conditions and hospitalizations
Family history
*
Please list medical conditions in the family including: siblings, parents, and grandparents.
Allergies
Please list all allergies past and present
Smoking and Recreational drugs
*
Never
Quit within the past year
Quit more than a year ago
Yes
Medications and supplements
*
List all medications and supplements (if not listed above). Please include dosages if possible, and when you started taking.
Estimated weight in pounds
*
Estimated height
*
Bowel movements
*
1 - 2 times/d
3 - 4 times/d
Every other day
Only a few times a day
Other
Diet category
*
Meal times
*
My typical times for breakfast, lunch, and dinner are?
Include snack times
Coffee intake
*
3+ per day
1 - 2 per day
Rarely
Never
I drink alcohol
*
Daily
A few times a week
Only weekends
Only social occasions
None
Frequency of physical activity
Direct sunlight each day?
I'm out in the sun often
Rarely
Hours of sleep
Bed time and wake time
*
When do you typically go to bed and when do you usually wake up?
Time to fall asleep
*
Almost immediately
Up to 15 mins
Up to 30 mins
Up to an hour
Beyond 2 hours
Energy level
1 = No energy
10 = bursting with energy
What you generally feel day to day, week to week
Worry
*
Over the last 2 weeks, have you experienced any of the following symptoms?
Mood
*
Over the last 2 weeks, have you experienced any of the following problems?
Stress
1 = No stress
10 = Very stressed. Near breaking point
What you feel generally (day to day, week to week)
Occupation is
*
My connection with my family is
*
Strong
Somewhat strong
Distant
Other
No comment
Sexually active
*
Yes
No
I am a spiritual person
*
Yes
Somewhat
No
Other
I am part of a spiritual community
*
Yes
No
Other
My spiritual practices are
Would you like to be added to our emailing list for clinic updates, promotions, and health information?
Yes
No
Best method of contact
How did you hear about the Clinic?
*
Family/Friend/Colleague
Referral from healthcare provider
Health benefits/Insurance company
Google
Facebook
Twitter
Instagram
Yelp
LinkedIn
Poster/Outdoor sign
Other
Comments
Please indicate any other comments you feel are necessary for us when considering your case