Natural Medicine Consultation Chart
|Date of Birth||Sex|
|Telephone:||May we leave a message related to your visit?|
Emergency Contact Information
Name: Telephone: Relationship:
How did you hear about our clinic?
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
|Arthritis||Other Mental Illness|
|Heart Disease||Thyroid Condition|
|High Blood Pressure||Kidney Disease|
I don't know my family history.
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?
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:
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?
Birth Control Pills
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