Adult Intake Packet
Personal Information
Name _________________________________________________Date____________________
Address _______________________________________________________________________
City_________________________________State _______________ Zip code ______________
Phone (hm)__________________ (wk) _____________________ (cell) ____________________
Preferred number for messages and appointment reminders?_______________________________
E-mail ______________________________ Social Security # ____________________________
Age _____ Date of birth ___________ Birth Gender: F M NG Identified Gender: F M NG ☐
Married ☐ Partnership ☐ Single ☐ Separated ☐ Divorced ☐ Widowed
Live with: ☐ Spouse or partner ☐ Parents ☐ Children ☐ Friends ☐ Alone
Occupation _______________________ Hours per week ________ Retired _______ Years _____
Employer _____________________________________________________________________
What is your ethnic heritage and/or cultural upbringing?__________________________________
Have you seen a Naturopathic Physician before? Yes_____ No______
Which one?____________________________________________________________________
How did you hear about this clinic?__________________________________________________
May we thank them for the referral? Yes________ No ________
Has any other family member already been a patient at the clinic?___________________________
______________________________________________________________________________
Emergency Contact: _____________________________________________________________
Relationship _____________________________________ Phone ________________________
CONTEXT OF CARE REVIEW
Successful health care and preventive medicine are only possible when the physician has a complete
understanding of the patient physically, mentally and emotionally. The nature of your responses to
the following questions will help me understand your needs and how to help you reach your health
goals. Your time, thoughtfulness and honesty in completing this overview will greatly aid me to
assist your health needs.
1) Why did you choose to come to this clinic? What do you know about our approach?
2) What three expectations do you have from this visit to our clinic?
What long term expectations do you have from working with our clinic? What expectations
do you have of me personally as your physician?
3) What is your present level of commitment to address any underlying causes of your signs and
symptoms that relate to your lifestyle? (Rate from 0 to 10, with 10 being 100% committed)
0% 0 1 2 3 4 5 6 7 8 9 10 100%
4) a) What behaviors or lifestyle habits do you currently engage in regularly that you believe support
your health? (please list)
b) What behaviors or lifestyle habits do you currently engage in regularly that you believe are selfdestructive lifestyle habits: (please list)
5) What potential obstacles do you foresee in addressing the lifestyle factors which are undermining
your health and in adhering to the therapeutic protocols which we will be sharing with you?
6) Who do you know that will sincerely support you consistently with the beneficial lifestyle changes
you will be making?
Current Health History
Do you have a Primary Care Provider? Y / N
If yes, please give their name, location, and phone number:________________________________
______________________________________________________________________________
Are you currently receiving other forms of healthcare (massage, physical therapy, etc)? Y / N If yes,
for what and from whom: ____________________________________________________
______________________________________________________________________________
If no, when and where did you last receive medical or health care?__________________________
______________________________________________________________________________
What was the reason?_____________________________________________________________
What are your most important health problems? List as many as you can in order of importance:
1)________________________________________________________________
2)________________________________________________________________
3)________________________________________________________________
4)________________________________________________________________
5)________________________________________________________________
6)________________________________________________________________
7)________________________________________________________________
Do you have any known contagious diseases at this time? Y N
If yes, what?___________________________________________________________________
Family History
Do you have a family history of any of the following (please circle)?
Cancer
Kidney Disease
Tuberculosis
IBD
Asthma/Hayfever/Hives
Diabetes
Epilepsy
Stroke
Allergies
Alcoholism
Heart Disease
Anemia
Arthritis
Osteoporosis
Glaucoma
Eczema
High Blood Pressure
Mental Illness
Any other relevant family history?__________________________________________________
Childhood Illnesses
Please circle whether you had any of these as a child:
Scarlet fever
Mumps
Chicken pox
Diptheria
Rheumatic fever
Measles
German measles
Mononucleosis
Polio
Tetanus
Measles/Mumps/Rubella
Hospitalization, Surgery, Imaging
What hospitalizations, surgeries, X-Rays, CAT Scans, EEG, EKG’s have you had?
__________________year:______
___________________year: ______
__________________year:______
___________________year:_______
__________________year:______
___________________year:_______
Allergies
Are you hypersensitive or allergic to...
Any drugs?_____________________________________________________________________
Any foods?_____________________________________________________________________
Any environmentals or chemicals?___________________________________________________
Exposures
Have you had daily or prolonged exposure to any toxic chemicals, paints, lead, mercury? Y N
If yes, what type and when? ______________________________________________________
Second hand smoke?
If yes, for how long? ________________________
Current Medications
Please list any prescription medications, over the counter medications, vitamins or other
supplements you are taking?
1)__________________________________ 5)__________________________________
2)__________________________________ 6)__________________________________
3)__________________________________ 7)__________________________________
4)__________________________________ 8)__________________________________
General
Height:_________ Weight:________ lbs. Weight 1 year ago:_______________________ lbs.
Maximum Weight:__________________ When:____________________________________
When during the day is your energy the best?_________________ worst?__________________
Typical Food Intake
Breakfast:________________________________________________________________
Lunch:__________________________________________________________________
Dinner:__________________________________________________________________
Snacks:__________________________________________________________________
Drinks:___________________________________________________________________
REVIEW OF SYSTEMS
Y= Yes, present condition. N=No, never had the condition. P=Problem of the past.
General
Dizziness
Y P N
Night Sweats
Y P N
Fatigue
Y P N
Head
Headaches
Y P N
Migraine headaches
Y P N
Jaw/TMJ problems
Y P N
Skin
Rashes
Y P N
Eczema, hives
Y P N
Color Changes
Y P N
Musculoskeletal
Joint Pain
Y P N
Muscle Spasms
Y P N
Weakness
Y P N
Neurological
Fainting
Paralysis
Numbness/tingling
Loss of Memory
Y P N
Y P N
Seizures
Y P N
Emotional
Mood Swings Y P N
Depression
Y P N
Nervousness
Tension/stressed
Y P N
Y P N
Anxiety
Y P N
Endocrine
Excessive thirst
Excessive hunger
Cold intolerance
Heat intolerance
Y P N
Y P N
Thyroid problems___________
Diabetes__________________
Y P N
Y P N
Y P N
Y P N
Respiratory/Cardiovascular
Cough
Y P N
Shortness of breath
Y P N
Asthma
Y P N
Heart Disease
Y P N
Low/High blood pressure________________________
Chest pain
Blood Clots
Y P N
Y P N
Gastrointestinal
Diarrhea
Y P N
Blood in stool Y P N
Constipation
Nausea/Vomiting
Y P N
Y P N
Stomach pain
Y P N
Urinary
Incontinence
Frequent infections
Y P N
Painful Urination
Y P N
Testicular masses
Y P N
Sexual difficulty
Y P N
Y P N
Male Reproductive
Hernias
Y P N
Female Reproductive
Age of first menses__________ Age of last menses (if menopausal)_______ Length of cycle_______
Duration of menses__________ Date of last annual exam______ Number of pregnances___________
Number of live births________ Number of miscarriages_______ Number of abortions_____________
Birth Control
Y N P
If yes, what type?