Naturopathic Intake Form (Page 4 of 4) in pdf

General Review of Systems:

Do you have any rashes, lumps, sores, itching, dry skin, change in hair or nails?

Y / N

If yes: _________________________________________________________________________________

Have you ever been unconscious, had a convulsion, have recurring headaches or had a head injury? Y / N

If yes: _________________________________________________________________________________

Any problems with hearing, ringing in the ears, dizziness, ear infections, discharge? Y / N

If yes: _________________________________________________________________________________

Any problems with teeth, gums, tongue, sore throats or hoarseness?

Y / N

If yes: _________________________________________________________________________________

Any problem with the eyes, including vision? Y / N

If yes: _______________________________________________________________________________________

Have you ever had a cough, wheeze, or asthma? Y / N

If yes: _______________________________________________________________________________________

Any recurring problem with vomiting, diarrhea, constipation or stomach pain? Y / N

If yes: _________________________________________________________________________________

Any unusual problem on passing urine or any unusual frequency? Any unusual smell or appearance to the urine? Y / N

If yes: __________________________________________________________________________________

Do you complain of any extremity or lower back pain? Y / N

If yes: ______________________________________________________________________________________

Have you ever had blackouts, seizures, weakness, paralysis, numbness or loss of sensation, tremors, or other

involuntary movements? Y / N

If yes: ___________________________________________________________

Do you have any thyroid trouble, excessive thirst or hunger, heat or cold intolerance, or diabetes? Y / N

If yes: ___________________________________________________________

Any allergies, eczema, hay fever, hives or drug reactions? Y / N

If yes: ___________________________________________________________

Do you have any intense fears, mood swings, or other sensitivities? Y / N

If yes: ___________________________________________________________

OTHER HEALTH CONCERNS & ADDITIONAL INFORMATION:

Naturopathic Intake Form Page 4