Naturopathic Intake Form
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425 -10815 Bathurst St.
Richmond Hill, ON L4C 9Y2
Tel.: 905-737-5559 Fax: 905-737-5556
NATUROPATHIC INTAKE FORM
Date: _______/_________/________
Last name:________________________ First name: ______________________ Middle name:_______________
Date of birth: ______/_____/_____
Sex: M F
Height: __________________ Weight: ________________
Address: __________________________________________________ City: _____________________________
Province: _______ Postal Code: ________-________ Email: __________________________________________
Daytime Phone number: (_____) _______-________ Evening time Phone number: (______) _______-________
Emergency contact: _________________________________________ Relationship: ______________________
Name of present MD: ______________________________________________ Phone (_____) _______-_______
Date of last medical doctor visit:____________________ Date of last physical exam:_______________________
Do you get regular screening tests done by another doctor (Pap, blood tests, etc.)?
Yes / No
How did you hear about us? ____________________________________________________________________
What are your health concerns, in order of importance to you:
1. ____________________________________________________________________
2. ____________________________________________________________________
3. ____________________________________________________________________
4. ____________________________________________________________________
5. ____________________________________________________________________
If you are female, are you currently pregnant?
Yes / No
Medical Health of Patient:
Please check item(s) which apply today or did in the past:
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Asthma
Constipation
Anxiety / Depression
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Diabetes
Diarrhea
Headaches
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Arthritis
Allergies
Heartburn
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Cancer ______________
High Cholesterol
Other _____________________________
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