Naturopathic Intake Form Page 2
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4Dr. Kathrine Tavakoli, ND
Who will sincerely support you consistently with the beneficial lifestyle changes you will be making?
___________________________________________________________________________________________________________
What do you LOVE to do? _____________________________________________________________________________________
HEALTH INFORMATION
Please list your health concerns (physical, emotional, or psychological) in order of importance to you and the date of onset:
1. _______________________________________________________
_______________
2. _______________________________________________________
_______________
3. ____________________________________________ ___________
_______________
4. _______________________________________________________
_______________
SUPPLEMENTS/DRUG MEDICATIONS
Please list all current vitamins/minerals, herbs, or homeopathic remedies, along with the daily dose and how long you have taken it.
Supplement
Dose/day
How long?
Reason for Supplement
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2.
3.
4.
5.
6.
Please list all current medications (prescription and over-the-counter), the daily dose, how long you have taken it, and the reason for the
prescription.
Medication
Dose/day
How long?
Reason for Medication
1.
2.
3.
4.
5.
6.
Are the medications well tolerated? Y N If no, please list the adverse reaction or side effect and from what medication:
________________________________________________________________________________________________________
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