Adult Intake Form
Please fill out this form to the best of your ability. It will help to assess your present health
and will assist in facilitating the healing process.
Preferred First Name: __________________________________________________________
Age: ___________________Height: _____________________
Max Weight: ____________________________
Weight: ___________________
When? _________________________________
What are your chief concerns?
1.
2.
3.
Describe your general overall state of health at present in less than 5 words:
______________________________________________________________________________________
______________________________________________________________________________________
List all prescribed medications currently taken and include dose, frequency, and how
long you have been taking them.
1.
2.
3.
List any medication allergies (for example penicillin)
______________________________________________________________________________________
______________________________________________________________________________________
List all over the counter medications that you take (for example aspirin, Tums, Tylenol)
and include dose and frequency.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
How many courses of antibiotics have you been on in the last 5 years? ________________
List all vitamins, minerals, herbal medicines, Asian medicines, or homeopathics you are
currently taking and include dosage.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
30 Edinburgh Rd N, Unit 2B, Guelph, Ontario, N1H 7J1 (519)822-7075
www.GuelphNaturopathicDoctor.com
Do you use any recreational drugs? If yes, indicate type and frequency of usage.
______________________________________________________________________________________
______________________________________________________________________________________
What type of vaccinations have you received?
______________________________________________________________________________________
Have you ever experienced an adverse reaction to the above vaccinations? __________
Describe your general state of health as a child. ______________________________________
Describe your general state of health as a teenager.__________________________________
Have any of your family members had any significant illness or health concerns?
______________________________________________________________________________________
______________________________________________________________________________________
Do you have siblings? _____________ How many? ________________________
List any conditions that may apply to your siblings.
______________________________________________________________________________________
______________________________________________________________________________________
List any surgeries and/or hospitalizations.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
List any severe accidents or injuries in the past.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
What is a typical food/drink day for you?
Breakfast:
Lunch:
Dinner:
Snacks:
Beverages:
Water:
Do you drink alcohol? If yes, what type, and how often?
__________________________________________________
Do you smoke? If yes, since when, and how many a day?
_________________________________________________
Do you exercise? ____________________________________________________________________
List your hobbies or interests.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
30 Edinburgh Rd N, Unit 2B, Guelph, Ontario, N1H 7J1 (519)822-7075
www.GuelphNaturopathicDoctor.com
What level of personal stress are you experiencing at the present moment?
minimal
average
considerable
unbearable
What are the main stressors in your life?
______________________________________________________________________________________
______________________________________________________________________________________
Please circle ‘Y’ if you are currently experiencing the condition. Please circle ‘P’ if you
had the condition in the past. Write comments as necessary.
SKIN
Itching
Acne (pimples)
Bruises easily
Hives (allergy)
Eczema
Boils
Dryness
Rosacea
Night sweats
Skin cancer
Change in moles
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
P
P
P
P
P
P
P
P
P
P
P
HEAD
Headaches/migraines
Head injury
Dizziness
Loss of hair
EYES
Glasses/contact lenses
Eye pain
Tearing
Dryness
Double vision
Glaucoma
Cataracts
Blurring
Bothered by sun
Blind spot
Night/colour blindness
EARS
Impaired hearing
Earache
Discharge
Infections
Ringing in ears
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
30 Edinburgh Rd N, Unit 2B, Guelph, Ontario, N1H 7J1 (519)822-7075
www.GuelphNaturopathicDoctor.com
NOSE
Frequent colds
Nose bleeds
Stuffiness
Hay fever
Sinus problems/infections
MOUTH AND THROAT
Frequent sore throats
Sore tongue/mouth
Gum problems
Hoarse voice
Loss of taste
Dry mouth
NECK
Pain or stiffness
Enlarged thyroid/glands
RESPIRATORY
Cough
Sputum
Wheezing
Asthma
Bronchitis
Difficulty breathing
Pain on breathing
Shortness of breath
Shortness of breath at night
Shortness of breath lying
down
CARDIOVASCULAR
Heart disease
Angina
High blood pressure
Chest pain
Swelling in ankles
Palpitations, fluttering
GASTRO-INTESTINAL
Heartburn
Change in thirst/appetite
Nausea/vomiting
Bowel movements - how often?
Blood in stool
Belching/passing gas
Jaundice (yellow skin)
Liver/gallbladder disease
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
P
P
P
P
P
P
P
P
P
P
P
Y
Y
P
P
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
P
P
P
P
P
P
P
P
P
P
Y
Y
Y
Y
Y
Y
P
P
P
P
P
P
Y
Y
Y
P
P
P
Y
Y
Y
Y
P
P
P
P
30 Edinburgh Rd N, Unit 2B, Guelph, Ontario, N1H 7J1 (519)822-7075
www.GuelphNaturopathicDoctor.com
Ulcer
Indigestion
Diarrhea/constipation
Hemorrhoids
Intestinal worms
Y
Y
Y
Y
Y
P
P
P
P
P
URINARY
Pain on urination
Increased frequency
Inability to hold urine
Frequent urinary infections
Kidney stones
Blood in urine
Y
Y
Y
Y
Y
Y
P
P
P
P
P
P
MALE
Testicular masses/pain
Are you or have you been
sexually active?
Sexual difficulties
Venereal disease
Discharge or sores
Y
Yes
No
Y
Y
Y
P
FEMALE
Age menses began
Average number of days of
menses
Average length of cycle
Bleeding between periods
Irregular cycles
Pain during intercourse
Painful menses
PMS
Excessive flow
Last menstrual period (date)
Last PAP (date)
Vaginal discharge
Vaginal itching
Are you or have you been
sexually active?
Difficulty conceiving
Birth control?
What type?
Number of pregnancies
Number of live births
Number of miscarriages
Number of abortions
Sexual difficulties
Venereal disease
Do you do self breast
P
P
P
Y
Y
Y
Y
Y
Y
P
P
P
P
P
P
Y
Y
Yes
P
P
No
Yes
Yes
Y
Y
No
No
P
P
30 Edinburgh Rd N, Unit 2B, Guelph, Ontario, N1H 7J1 (519)822-7075
www.GuelphNaturopathicDoctor.com
exams?
Lumps/pain/discharge
Y
MUSCULOSKELETAL
Joint pain or stiffness
Arthritis
Broken bones
Muscle spasms or cramps
Backache
Foot pain
P
Y
Y
Y
Y
Y
Y
P
P
P
P
P
P
PERIPHERAL VASCULAR
Deep leg pain
Cold hands/feet
Varicose veins
Extremity
numbness/coldness/swelling
Y
Y
Y
Y
P
P
P
P
NEUROLOGICAL
Fainting
Seizures/convulsions
Paralysis
Loss of memory
Involuntary movement
Loss of balance
Speech problems
Y
Y
Y
Y
Y
Y
Y
P
P
P
P
P
P
P
ENDOCRINE
Heat intolerance
Cold intolerance
Thyroid abnormalities
Excessive thirst/hunger/urination
Excessive sweating
Diabetes
Hypoglycemia
Hormone therapy
Y
Y
Y
Y
Y
Y
Y
Y
P
P
P
P
P
P
P
P
BLOOD/LYMPHATIC
Anemia
Easy bleeding/bruising
Lymph node swelling
EMOTIONAL
Depression
Mood swings
Anxiety or nervousness or
tension
Alcohol/Drug abuse
Insomnia
Y
Y
Y
P
P
P
Y
Y
Y
P
P
P
Y
Y
P
P
30 Edinburgh Rd N, Unit 2B, Guelph, Ontario, N1H 7J1 (519)822-7075
www.GuelphNaturopathicDoctor.com
What are the health goals you are hoping to achieve during your treatment time at this
clinic?
1.
2.
3.
4.
5.
Thank you for answering all the questions. Complete answers to all of the questions are
to your benefit for the most effective naturopathic treatment. This is a confidential
record of your medical history and will be kept in this office. Information contained here
will not be released to any person except when you have authorized us to do so.
30 Edinburgh Rd N, Unit 2B, Guelph, Ontario, N1H 7J1 (519)822-7075
www.GuelphNaturopathicDoctor.com