Name
*
First Name
Last Name
Sex
*
Male
Female
Age
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
*
Phone
(###)
###
####
Name
*
First Name
Last Name
Phone
*
(###)
###
####
List of Providers
List other health care providers you currently work with (name and profession will suffice).
Insurance coverage
*
Does your extended health care plan cover naturopathic medicine?
Personal medical history
*
Please list past medical conditions and hospitalizations
Family history
*
Please list medical conditions in the family including: siblings, parents, and grandparents.
Blood tests and Labs
*
In the past year, which tests have been performed? Please indicate all that apply.
Dental check-up in past year?
*
Allergies
Please list all allergies past and present
Smoking and Recreational drugs
*
Never
Quit within the past year
Quit more than a year ago
Yes
Medications and supplements
*
Please include dosages if possible, and when you started taking.
Estimated weight in pounds
Estimated height
Symptoms
Please check any of the below that you have noticed recently
Bowel movements
*
3 - 4 times/d
1 - 2 times/d
Every other day
Only a few times a day
Description of flow
Description of menstrual flow (color, volume, etc)
Diet category
*
Meal times
*
My typical times for breakfast, lunch, and dinner are?
Include snack times
I eat fruit
*
Every meal
At least one meal
Only as a snack
A few times a week
Once a week
Rarely
I eat vegetables
*
Every meal
At least one meal
Only as a snack
A few times a week
Once a week
Rarely
Do you take smoothies?
*
Green smoothies
Fruit smoothies
None
Other
My grains are
*
Refined (White bread, white rice)
Whole grain (Brown bread, brown rice)
Mixed
Enriched
I don't eat grains
I eat grains
*
Every meal
Only about once a day
A few times a week
Once a week
Rarely
I don't eat grains
Types of oil I use
*
Click all that applies
I use oil for
*
I enjoy fried foods
*
Almost daily
A few times a week
Rarely
I eat nuts
*
Almost every meal
Daily
A few times a week
Once a week
Rarely
I eat beans
Almost every meal
Daily
A few times a week
Once a week
Rarely
I eat meat
*
Almost every meal
Daily
A few times a week
Once a week
Rarely
I eat dairy products
*
Every meal
Daily
A few times a week
Once a week
Rarely
Snack foods I enjoy are
I eat out
*
About once a day
Few times a week
Once a week
Rarely
I drink water
*
Throughout day
A little throughout the day
I don't drink much water
Cups of coffee per day
*
3+
1 - 2
Rarely
Never
Cups of tea per day
*
3+
1 - 2
Rarely
Never
I drink juices
*
Almost every meal
Daily
A few times a week
About once a week
Rarely or never
I drink fluids with my meals
*
Yes
No
I drink alcohol
*
Daily
A few times a week
Only weekends
Only social occasions
None
Current physical activities
*
Please share with us what types of exercise activities you are currently engaged in
Activity preferences
Please list any activities you would like to explore and also activities you absolutely dislike doing.
Equipment available at home are
Click all that apply
How do you travel to and from work?
*
Gym membership
Have membership
No - not interested
No - interested
No - interested but financially difficult
Barriers to physical activity
List if any
Direct sunlight each day?
*
I'm out in the sun often
Rarely
Typical hours of sleep each night
I feel well rested after sleeping
*
Generally yes
Generally no
It varies
Bed time and wake time
*
When do you typically go to bed and when do you usually wake up?
Time to fall asleep
*
Almost immediately
Up to 15 mins
Up to 30 mins
Up to an hour
Beyond 2 hours
Wake up in the middle of the night?
*
Yes to use bathroom
Yes for no particular reason
Yes due to nightmares
Rarely
Other
Worry
*
Over the last 2 weeks, have you experienced any of the following symptoms?
Mood
*
Over the last 2 weeks, have you experienced any of the following problems?
Occupation is
*
How do you feel about your job and role?
*
My connection with my family is
*
Strong
Somewhat strong
Distant
Other
No comment
Sexually active
*
Yes
No
Number of sexual partners
*
I am a spiritual person
*
Yes
Somewhat
No
Other
I am part of a spiritual community
*
Yes
No
Other
My spiritual practices are