Naturopathic Intake form

Please complete the information you are comfortable sharing. You may leave a question blank to discuss it during your appointment. Unanswered questions do not mean that a symptom or condition is absent.

General Health Information

Please list your primary health goals and concerns, in order of importance: Optional

Please list all of your current healthcare providers (name, professional title): Optional

Please list all diagnoses, conditions, surgeries, hospitalizations, and major injuries (including dates): Optional

Please describe all imaging you’ve had completed (e.g. ultrasound, x-ray, CT or MRI): Optional

Please list the treatments you’ve tried in the past and the results (Acupuncture, Cupping, Massage, Physiotherapy, etc.): Optional

Please list all allergies, sensitivities, and intolerances (including food, drugs, and environmental): Optional

Please list all supplements and medications you currently take. Include start date, dose, and reason for taking: Optional

Please list all supplements and medications you have taken in the past: Optional

Please describe what you eat and drink in a typical day:

Breakfast Optional

Lunch Optional

Dinner Optional

Snacks Optional

Beverages Optional

How much and how often do you consume the following:

Water Optional

Caffeine Optional

Tea (what kind?) Optional

Energy drinks Optional

Artificial sweetener (e.g. Splenda, NutraSweet) Optional

Tobacco Optional

Alcohol Optional

Cannabis or recreational drugs Optional

Eating out (e.g. restaurant, takeout) Optional

Please describe what forms of exercise you participate in, how often, and the duration per week: Optional

How many hours of sleep do you get each night on average? Please describe your sleep quality (e.g. snoring, restlessness, fatigue on waking): Optional

Briefly describe your travel history: Optional

What do you LOVE to do? How often do you get to do these things? Optional

Do you have any concerns regarding your mental or emotional health? Please describe: Optional

Please rate how happy you are generally, between 1 (very sad) and 10 (very happy): Optional

Very sad Very happy

Please rate your energy levels between 1 (almost none) and 10 (most you’ve ever had): Optional

Almost none Most energy

Please rate your stress levels between 1 (no stress) and 10 (most stress ever experienced): Optional

No stress Most stressed

What are your top 3 sources of stress? Optional

How do you manage your stress? Optional

Please list names and ages of all persons currently residing in your home: Optional

Are you or were you ever regularly exposed to any of the following at home or work? If yes, please describe:

Which of these have you been regularly exposed to at home or work, now or in the past? Optional

Smoke (e.g. cigarettes, cannabis, fires)Chemicals/toxins (e.g. pesticides, house cleaners)Animals (including pets, farm animals)Radiation (e.g. x-rays, electromagnetic radiation/EMFs)Well waterHeavy Metals (e.g. stained-glass making, welding, manufacturing, old gas stations)Radon gasMould and mycotoxins (e.g. water damaged rooms or buildings)

Describe applicable exposures below. Leave unrelated detail fields blank.

Smoke (e.g. cigarettes, cannabis, fires) Optional

Chemicals/toxins (e.g. pesticides, house cleaners) Optional

Animals (including pets, farm animals) Optional

Radiation (e.g. x-rays, electromagnetic radiation/EMFs) Optional

Well water Optional

Heavy Metals (e.g. stained-glass making, welding, manufacturing, old gas stations) Optional

Radon gas Optional

Mould and mycotoxins (e.g. water damaged rooms or buildings) Optional

Please complete this section if chronic pain (pain that persists longer than 3 to 6 months) is one of your reasons for seeking care. Brief answers are welcome, and you may skip any question you would prefer to discuss during your appointment.

These questions help us understand your symptoms, their impact, and your priorities.

Where do you experience pain? Select all that apply. Optional

Head or faceNeckShoulderUpper backMid backLower backChest or ribsAbdomenPelvis or hipArm or elbowWrist or handThigh or kneeLower legAnkle or footOther

Pain location details Optional

In each painful area, please describe what your pain feels like: Optional

Please describe how often you experience pain: Optional

What tends to make your pain better or worse? Optional

Have you ever noticed any times when your pain is less noticeable, or you can do more than expected? Optional

When and how did your pain begin? Optional

How has your pain changed over time? Optional

Do you experience any symptoms that are associated with your pain? Optional

What number best describes your pain on average in the past week? Optional

No pain Pain as bad as you can imagine

What number best describes how, during the past week, pain has interfered with your enjoyment of life? Optional

Does not interfere at all Completely interferes

What has pain made harder in your daily life? Optional

What specific activities would you like to do more comfortably or confidently? Optional

What are you still able to do or enjoy, and what helps you keep doing it? Optional

What is your understanding of your pain? Optional

Please indicate which conditions apply to you OR in the recent past. If you’re unsure, please check the item and discuss it with your health practitioner. Leaving an item unchecked does not confirm that it is absent.

Constitutional Optional

Recent unintentional Weight GainRecent unintentional Weight LossUnexplained persistent fatigue

Constitutional — additional details about any of the above: Optional

Musculoskeletal Optional

Low back painMid back painUpper back painNeck painArm problemsLeg problemsJaw problemsPainful jointsStiff/swollen jointsWeak musclesMuscle spasm, tremor, or sprainOsteoporosis or osteopeniaBroken bonesReduced mobilityOther

Musculoskeletal — additional details about any of the above: Optional

Neurological Optional

Nerve pain, neuropathy, or neuropathic painNumbness or tingling sensationLoss of sensationDizziness or light-headedFrequent or recurrent headaches or migrainesConvulsions or seizuresTremorsStrokeHistory of head injuryHistory of auto accidentSpeech difficultyDifficulty with memory or word recallLearning or language disorderOther

Neurological — additional details about any of the above: Optional

Mental Health Optional

AnxietyDepressionMemory loss or confusionBrain fogEmotional traumaAddictionOther

Mental Health — additional details about any of the above: Optional

Digestion Optional

Loss of appetiteIncreased appetiteChange in bowel movementPainful bowel movementsBlood in stoolNausea or vomitingAbdominal painDiarrheaConstipationBloating/Gas/IndigestionHeartburn/Acid reflux/GERDGallbladder issues (e.g. gallstones, gallbladder removed)Hemorrhoids or rectal bleedingOther

Digestion — additional details about any of the above: Optional

Cardiovascular Optional

Chest painsRapid or irregular heart beatHigh blood pressureLow blood pressureSwelling of hands, ankles, feetClotting issues, heart attackVaricose veinsShortness of breath when climbing stairsFainting, light-headedness, or vertigoEasy bleeding or bruisingAnemia, blood disorder, or blood vessel disorderCold hands and/or feetOther

Cardiovascular — additional details about any of the above: Optional

Immune System Optional

Slow wound healingRecurrent fevers, sweats, or chillsRecurring infections (e.g. cold sores, strep throat, colds, sinusitis)Autoimmune conditionFrequent sinus congestion or painSwollen lymph nodes or tonsilsTick bite historyHospitalization due to infection or immune-related illnessOther

Immune System — additional details about any of the above: Optional

Hormones Optional

Difficulty losing weight, or gaining weight easilyDifficulty gaining weightFertility concernsLibido concernsMenstrual cycle pain, irregularity, or PMSErectile dysfunctionBlood sugar dysregulation (high or low)Thyroid disorderOther

Hormones — additional details about any of the above: Optional

Respiratory Optional

Difficulty breathing or Shortness of BreathPersistent cough or throat-clearingCoughing bloodAsthma or wheezingCOPD or other lung disorderNasal congestionUse of inhalers or nasal spraysOther

Respiratory — additional details about any of the above: Optional

Hair, Skin and Nails Optional

Rash, itchy or dry skinAcneRosaceaEczema, psoriasis, or other skin conditionHivesChange in skin colorChange in moleFungal infection (e.g. dandruff, toe nails)Excessive hair growth in unwanted areasHair loss or unexpected changes in hairUnexpected changes in nails (i.e. pitting, lines, ridges)Brittle or weak nailsOther

Hair, Skin and Nails — additional details about any of the above: Optional

Ears, Nose, Mouth and Throat Optional

Hearing lossRinging in earsEar-acheEar infectionsSinus problems or infectionsNose bleedsPost-nasal dripBleeding gums or soresBad breath or bad tasteDry mouth or saliva problemsDental problemsTeeth grinding or clenchingSwollen throatTrouble swallowingOther

Ears, Nose, Mouth and Throat — additional details about any of the above: Optional

Eyes and Vision Optional

Wear contacts or glassesBlurred or double visionGlaucomaEye disease or injuryEye floatersFlashes in visionDry eyesOther

Eyes and Vision — additional details about any of the above: Optional

Genitourinary Optional

Increased frequency of urinationDifficulty holding urinePainful urinationChange in force/strain with urinationIncontinence or bed wettingKidney stonesBlood in urineProstate concernsSexual difficultyOther

Genitourinary — additional details about any of the above: Optional

Have any of your family members experienced any of the following health concerns? Please describe relation and onset of condition:

Which health concerns have occurred in your family? Optional

Mental illness (e.g. depression, anxiety, bipolar disorder, addiction)Cardiovascular disease (e.g. heart attacks, stroke, hypertension, high cholesterol)Immune disorders (Crohn’s, Rheumatoid Arthritis, Multiple Sclerosis, immune deficiency)DiabetesCancerSkin conditionsAllergiesInherited conditions (e.g. bleeding disorders, cystic fibrosis)Lung disease (e.g. asthma, COPD)Developmental delays, birth defects, speech or language disordersOther

For applicable concerns below, describe the family relationship and when the condition began.

Mental illness (e.g. depression, anxiety, bipolar disorder, addiction) Optional

Cardiovascular disease (e.g. heart attacks, stroke, hypertension, high cholesterol) Optional

Immune disorders (Crohn’s, Rheumatoid Arthritis, Multiple Sclerosis, immune deficiency) Optional

Diabetes Optional

Cancer Optional

Skin conditions Optional

Allergies Optional

Inherited conditions (e.g. bleeding disorders, cystic fibrosis) Optional

Lung disease (e.g. asthma, COPD) Optional

Developmental delays, birth defects, speech or language disorders Optional

Other Optional

Additional Information

Is there anything else you would like to mention in this form? Optional

What would make a care plan realistic for you right now? Optional

Naturopathic Intake form

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