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Naturopathy New Patient Intake Form

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Naturopathy New Patient Intake Form BYRNE CHIROPRACTIC AND WELLNESS CENTER NEW NATUROPATHY CLIENT INFORMATION FORM Page 1 of 2 Please print clearly: Name ___________________________________________________ Date ____________________ Address _________________________________________________ Apt.# ___________________ City __________________________________ State __________ ZIP ____________________ Cell Phone (_____) _____ - ________ Is it okay to send text messages? Yes__ No__ Home Phone (_____) _____ - ________ Work Phone (_____) _____ - ________ E-mail Address __________________________________ *REFERRED BY: ______________________________ Your Occupation _______________________________ Employer ____________________________ Date of Birth ____________ Age _______ Gender: Male/Female Overall Health (circle one): Excellent / Good / Fair / Poor / Other ________________________________ Chief Complaint (the reason you’re here) __________________________________________________ Previous treatments of this complaint ______________________________________________________ Other complaints or problems ____________________________________________________________ Are you currently under the care of a physician or other healthcare professional? Physician Name _______________________________________ Date of last visit _________________ Current Medications/drugs/nutritional supplements ____________________________________________________________________________________ ___________________________________________________________________________________ ____________________________________________________________________________________ BY NOT DISCLOSING ALL MEDICATIONS, YOU MAY BE AT HIGHER RISK FOR HERBAL AND MEDICINE INTERACTIONS. PLEASE INTIAL THAT YOU HAVE READ AND ACKNOWLEDGE THIS STATEMENT. ______ Do you smoke/vape/chew tobacco? Do you drink coffee or alcohol? (if yes, indicate how much and how often) Cigarettes, cigars, etc. _________________ Coffee _________________ Alcohol _________________ NEW CLIENT NATUROPATHY INTAKE 2 0F 2 List any major illnesses (with approx. dates) ____________________________________________________________________________________ ____________________________________________________________________________________ List any surgery or operations (with approx. dates) ____________________________________________________________________________________ ____________________________________________________________________________________ Past Accidents or injuries _____________________________________________________________________________________ Marital Status: Single/Married/Divorced/Widowed Name of Spouse _____________________________ Describe Health of Spouse ________________________________ Number of children, if any _________ Names of Immediate Family Age Gender Any physical conditions or concerns? _____________________ ____ Male/Female __________________________________________ _____________________ ____ Male/Female __________________________________________ _____________________ ____ Male/Female __________________________________________ _____________________ ____ Male/Female __________________________________________ Any family history of serious illness (circle all that apply) Cancer / Diabetes / Heart / Other ____________________________________________________________________________________ Any household pets or other animals you or your family members are in close contact with _________ ____________________________________________________________________________________ What can we do to make you happier? ____________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ CONSENT IMPORTANT: By signing below, I understand that the suggested nutritional program and dietary information is not intended as primary therapy for any disease or symptom. My intention is to find a good nutritional program that will assist me in changing my habits and establishing a new lifestyle in order to build good health naturally. I understand that this dietary health program is not for the diagnosis, cure, mitigation, treatment or prevention of disease; this is an adjunctive schedule of nutrients solely provided to upgrade the quality of foods in my diet in order to supply good nutrition for supporting the physiological and biochemical processes of the human body. I fully understand that the naturopathic practitioner I am visiting is not a medical doctor (MD) and does not treat or diagnose medical conditions; that is not a replacement for medical counseling; that if I have a medical condition, I will seek a licensed professional of allopathic/orthodox medicine. I agree I am not seeking specific treatment, but an overall increase in my health status. I accept this information and agree to the conditions specified. I am not on this visit or any subsequent visit an agent for federal, state, or local agencies or on a mission of entrapment or investigation. I understand that it is my personal decision whether or not to follow the natural health recommendations offered. ___________________________________________________ _________________________________ PATIENT / AUTHORIZED PERSONS SIGNATURE Signature: _____________________________ Date ____________________ .
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