Natural Medicine Consultation Chart

Name Date
Date of Birth Sex
Address: City/Town
Province Postal Code
Telephone: May we leave a message related to your visit?

Emergency Contact Information
Name: Telephone: Relationship:

How did you hear about our clinic?
Referred by:

Other health care providers you are seeing:

Main concern: How long has this condition persisted? Previous treatments and results:

Other health concerns, in order of importance to you:

If you are female, are you currently pregnant? Yes No

Family History

  Who?   Who?
Allergies Depression
Arthritis Other Mental Illness
Asthma Drug Abuse/Alcoholism
Heart Disease Thyroid Condition
High Blood Pressure Kidney Disease
Cancer Other

I don't know my family history.


Occupation Hobbies

Do you exercise regularily? Yes No
What do you do for exercise? For how long/how much? How often?

How many hours per night do you sleep? Do you wake up during the night? Yes No When? How often?

How would you describe the emotional climate of your home? How stressful is your work or other aspects of your life?

Are you frequently exposed to second-hand smoke? Yes No
Are you frequently exposed to animals? Yes No

How is your home heated? Please describe any toxins or other hazards you are regularly exposed to (through work, home, hobbies):

Add anything you feel is important that has not been covered:

Medical History

How would you describe your general state of health?
Excellent Good Fair Poor

Please indicate any serious conditions, illnesses or injuries, and any hospitalizations; along with dates. Do you have any allergies? (Medicinal, environmental, etc)

Please list all current medications

Do you frequently use any of the following? Aspirin Laxatives Antacids Diet Pills Birth Control Pills Implants Injections
Alcohol How much/day or week Tobacco Form and amount/day Caffiene Form and amount/day Recreational Drugs What and how often

Do you get regular screening tests from another doctor? (Pap, blood, etc) Yes No


Do you have any food allergies or intolerances? Do you have any dietary restrictions? (Religious, vegitarian/vegan, etc)

Describe what you would eat in a typical day:
Breakfast: Lunch: Dinner: Snacks: Beverages and total quantity