GENERAL INFORMATION:

Name: _______________________________________________________
Date of Birth: ____________________________

Date _______________________

Age: ______________

Address: __________________________________________________________________________________
City:________________________________ State: _____________________

Zip: ____________________

Email: ____________________________________________________________________________________
Home: __________________

Work: __________________

Date of your last complete checkup: _________________

Cell: __________________________

Practitioner: ________________________________

Have you ever had acupuncture or seen a naturopathic doctor before? __________________________________
Who and when? ______________________________________________________________________
EMERGENCY CONTACT:
Name: __________________

Relationship: ___________________

Phone_________________________

How did you hear about us? ___________________________________________________________________

Please complete this questionnaire as fully as possible. This information is for clinic use only and is confidential.

PRESENT HEALTH CONCERNS:

Please list your health concerns in order of their significance to you.
1. ________________________________________________________________________________________
2. ________________________________________________________________________________________
3. ________________________________________________________________________________________
4. ________________________________________________________________________________________
5. ________________________________________________________________________________________
What other treatments have you tried for these conditions? Please describe the effects.

MEDICAL HISTORY:
Ear Infections
Allergies
Car accident
Heart disease
Bronchitis/Pneumonia
Rheumatic fever
Drug addiction
Acid Reflux
Arthritis
Asthma
Celiac Disease
Neurological condition
Bladder infection
Liver disease
Miscarriage

Thyroid disease
Rheumatic fever
Endometriosis
Herniated disc(s)
Psychological condition
Genetic disease
Tonsillitis
Strep Throat
Hepatitis A, B or C
Lyme disease
Shingles
Mono
Alcoholism
Gallbladder disease
Anemia

Pancreatitis
Broken bone(s)
Kidney disease
Menopause
High blood pressure
Infertility
Post-traumatic stress
PMS/Dysmenorrhea
Polycystic Ovaries

Please complete this questionnaire as fully as possible. This information is for clinic use only and is confidential.

Please describe:

Hospitalizations (year and reason):

Surgeries (year and reason):

Serious injuries or illnesses:

Allergic reactions (drugs, foods, pollen, other):

What happens when there is a reaction?

X-rays, Chemotherapy, Radiation or Special Studies

Please complete this questionnaire as fully as possible. This information is for clinic use only and is confidential.

MEDICATIONS:
Please list all medications that you take, including vitamins, herbs, contraceptives and pharmaceuticals. Include
the dose if you know them. Please bring your supplement bottles with you to your appointment so the
doctor can assess them.

FAMILY HISTORY:
Cancer: ___________________________________________________________________________________
Diabetes, type 1 or 2: ________________________________________________________________________
Heart Disease: ______________________________________________________________________________
Thyroid Disease: ____________________________________________________________________________
Autoimmune Disease ________________________________________________________________________
Arthritis: __________________________________________________________________________________
Depression: ________________________________________________________________________________
Anxiety:___________________________________________________________________________________
Asthma: ___________________________________________________________________________________
Anemia: ___________________________________________________________________________________
Osteoporosis:_______________________________________________________________________________
Kidney Disease: ____________________________________________________________________________
Hepatitis: __________________________________________________________________________________
Allergies food or environmental: _______________________________________________________________
Celiac Disease: _____________________________________________________________________________
Alcoholism: ________________________________________________________________________________
Do you or have you ever smoked?
If yes, how much for how long? __________________________________________________________
Do you drink alcohol?
If yes what kind, how much and how often? ________________________________________________
Do you drink coffee?
How much, what kind, how often? ________________________________________________________
How often do you cook? ______________________________________________________________________
How many hours do you work a week on average? _________________________________________________

Please complete this questionnaire as fully as possible. This information is for clinic use only and is confidential.

OCCUPATION:
Describe your current exercise routine.

How much sleep do you get a night on average? ___________________________________________________

Any trouble sleeping? ________________________________________________________________________
DIET:
Are you following any particular diet? ___________________________________________________________
What has been eliminated? ____________________________________________________________________
Why? _____________________________________________________________________________________
For how long? ______________________________________________________________________________
Did you feel any better without the foods? _______________________________________________________
Typical Breakfast:

Typical Lunch:

Typical Snacks:

Typical Dinner:

Thank you for your patience in filling out this form.

Please bring copies of any lab work or medical records if you are able to.

Submit
Please complete this questionnaire as fully as possible. This information is for clinic use only and is confidential.