IRIE NATURAL CENTER FOR HEALTH
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ADHS
Supply dates of above studies.
Using Contraceptives?
Yes
No
MEDICAL HISTORY. Have you suffered from any of the following?:
ADD/ADHD
Alcoholism
Anemia
Crohn's disease
Anorexia
Arthritis
Asthma
Eating Disorder
Autism
Blurry vision
Cancer
Headaches/Migraines
Cramping
CVS
Diabetes
High Blood Pressure
Ear ringing
Fibromyalgia
Glaucoma
Heart Disease
Hepatitis
Hernia
HIV or AIDS
Joint Pain
Intestinal disorders (GERD, etc)
Kidney Disease
Multiple Sclerosis
Muscle Spasms
Nasal fractures
Nausea/Vomiting
Mental Health (anxiety, PTSD)
Painful Menstruation
Rectal Bleeding
Seizures/Epilepsy
Sinus Issues
Sleep Disorders
STDs
Stroke/Paralysis
Thyroid Issues
Do any of the above run in your family? Who?
Surgical History/Dates:
Last physical or lab work.
Last Name:
*
Are you on any medications? List or provide list.
Do you have a Primary Care doctor?
Yes
No
First Name:
*
Emergency Contact:
*
SOCIAL HISTORY. Select all that apply:
Single
Married
Significant other
Other
DIAGNOSTIC STUDIES. What diagnostic studies have you had?
MRI
CT SCAN
EKG
Xrays
Ultrasound
Other
PAIN LOCATION. Briefly describe the pain location.
Weight:
*
INTAKE FORM
Pregnant?
Yes
No
Email:
*
Check here to receive email updates
Height:
*
Zip:
City:
*
Vitamins/Supplements?
Rate your Pain today: (0 - no pain; 10 - worst possible).
Do you have any diet restrictions?
Yes
No
State:
*
Allergies to medications/Reactions?
What is your goal for today?
Address:
*
Do you exercise regularly? Describe.
If "yes" describe
Do you use any of these regularly?
Coffee/Black Tea/Cola
Alcohol
Recreational Drugs
Tobacco, current past
Simple sugar (fructose) fast food
Breastfeeding?
Yes
No
DOB:
*
Have you ever consulted a Naturopathic Physician, Nutritionist, Counselor or other Alternative healthcare provider?
Yes
No
Contact Phone:
*
By signing this document you are agreeing that the information given is to the best of your knowledge. As part of the intake the doctor will base their recommendation on the information given. I certify that the information provided in this document is true to the best of my ability.
Name of primary care doctor:
Do you have children?
Yes
No
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