Naturopathic Intake Form (Page 3 of 4) in pdf

Naturopathic Intake Form Page 3

Dr. Kathrine Tavakoli, ND

________________________________________________________________________________________________________

MEDICAL HISTORY

Please indicate if you have had any of the following diagnostic tests performed:

Notable finding:

Thyroid Panel Y N

Cholesterol Y N

Liver Panel Y N

Hormone level Y N

Complete Blood Count Y N

EKG Y N

Blood Sugar test Y N

Chest x-ray Y N

Colonoscopy Y N

Mammography Y N

Please list any past surgeries or hospitalizations with the approximate dates:

1. __________________________________________________________

___________

2. __________________________________________________________

___________

3. __________________________________________________________

___________

Please list all past injuries (ie. Broken bones, joint sprains, burns, falls, car accidents etc.) with dates:

1. __________________________________________________________

___________

2. __________________________________________________________

___________

3. __________________________________________________________

___________

List all dental work and the approximate date of the procedure (root canal, mercury or ceramic fillings, implants, caps, dentures):

1. __________________________________________________________

___________

2. __________________________________________________________

___________

3. __________________________________________________________

___________

What is your blood type?

 A+

 B+

 O+

 AB+  A-

 B -

 O-

 AB-

Rate your stress level (10 = high)

Naturopathic Intake Form Page 3

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