Health History Form (General) printable pdf download

Family Naturopathic Clinic Adult Intake and Consent Form

Health History Form (GENERAL)

Name__________________________________ Birth-date ________________ Date__________________ MSP #__________________

Blood Type_________ Address___________________________________________ City _________________ Prov/State____________

Postal Code_________________ Phone (home)________________________________ Phone (work) ____________________________

best time to call _________________ Can we leave messages for you here? Y

Email __________________________________

Occupation________________________________________________________________________________ full-time

part-time

Emergency contact ___________________________________relation? ___________________Phone____________________________

How did you hear about us?________________________________________________________________________________________

Please list below all other health professionals you are currently seeing (complimentary and conventional) and their contact numbers.

Include their area of practice (GP, Chiropractor, etc...)___________________________________________________________________

____________________________________________________________________________________________

When was your last blood test?_________________ What kind?___________________________________________________________

Current Health Concerns:

What is your main reason for seeking naturopathic care?.________________________________________________________________

____________________________________________________________________________________________

How long has this been troubling you? ___________________________Has it been getting: better

worse

remaining the same

List any treatments you have had for this condition (surgery, acupuncture, massage, etc...) and the results. Include dates: ______________

____________________________________________________________________________________________

In order of importance, list any other health concerns that are troubling you:

1) ________________________________________________________________________________________Since when?__________

2) ________________________________________________________________________________________Since when?__________

3) ________________________________________________________________________________________Since when?__________

4) ________________________________________________________________________________________Since when?__________

Other concerns:__________________________________________________________________________________________________

List all medications, supplements, herbs, and homeopathic medicines you are currently taking. Include dosage and results: ____________

____________________________________________________________________________________________

If you have been treated homeopathically in the past, please list the remedies taken, at what dose (strength and frequency) and with what

___________________________________________________________________

results?________________________

____________________________________________________________________________________________

Health History Form (General)