Welcome to Simply Your Health! Adult Intake Form We’re excited to get to know you better. Please complete this form so we can provide you with the best care possible. All information is kept strictly confidential. It should take about 10–15 minutes to complete. Please fill out all required fields (*) carefully. Name* Date of Birth* Address* City* State* Postal Zip Code* Country* Occupation Telephone – Home Telephone – Work Telephone – Cell Email* Your Gender:* MaleFemale Number of Children Health Concerns List your five (5) top health concerns in order of importance (#1 being the most important): Medical History Major illnesses, injuries, or surgeries (and when they occurred): Allergies Drug Allergies: Food Intolerances: Environmental Sensitivities: General Information Height Weight Weight 1 year ago Blood Type Dental Do you have any root canals? YesNo If yes, how many? Do you have any amalgam fillings? YesNo If yes, how many? Habits Do you exercise? YesNo If yes, how often? Do you smoke? YesNo If yes, how long? How many per day? Do you use recreational drugs? YesNo If yes, which ones? Rate your energy (1 low – 10 high): 12345678910 Rate your stress (1 low – 10 high): 12345678910 Sleep How many hours of sleep do you get per night on average? Do you have difficulty falling asleep? YesNo Do you wake up during the night? YesNo If yes, how often? Do you feel refreshed in the morning? YesNo Digestive Health How frequently do you move your bowels? Do you experience any of the following? Loose stoolsDiarrheaHard stoolsDifficulty Passing stoolsMucous in stoolsGasBloatingHeartburn / RefluxBlood in StoolsAbdominal PainUndigested Foods in Stools Do you have your gallbladder? YesNo Do you have your appendix? YesNo Female Reproductive Age of first menses How many days of menses? How long is your cycle? When was your last pap test? Do you get yeast infections? YesNo History of abnormal pap? YesNo Are you menopausal? YesNo If yes, age of last menses? If you experience PMS, which symptoms do you experience? Pain or crampingHeadachesMood SwingsBloatingBreast TendernessCravings Other symptoms: Hot flashesLow libidoDisrupted sleepPain during intercoursePoor memoryChanges in moodVaginal itchingVaginal dryness Male Reproductive Indicate if any apply: ImpotenceTesticular painSores on GenitalsSexually Transmitted DiseaseInfertility/Low Sperm CountDischargeTesticular MassProstate Condition Are you sexually active? YesNo Form of contraception Health History Check any that apply to you or write P if experienced in the past: General FatigueChange in appetiteChange in thirstCravingsWeight gainWeight lossPoor sleepChills or feverNight sweatsSweat easilyAllergiesCancerDiabetes Skin & Hair DrynessRashItchingEczemaPsoriasisAcneRecent molesHives/allergic reactionsLoss of hairThinning hairDandruffOther skin problem(s) Eyes, Ears, Nose & Throat Eye painEye strainBlurry visionImpaired visionCataractsEar achesEar infectionsRinging in earsVertigo or dizzinessSinus infectionsNasal obstructionPost nasal dripNosebleedsLoss of smell/tasteTonsillitisSores in mouthMercury fillingsJaw pain or clicksRecurrent sore throatEnlarged glandsEnlarged thyroidFacial pain/ticsHeadaches Cardiovascular Chest painPalpitationsHigh blood pressureLow blood pressureHeart attackCongestive heart failureIrregular heartbeatPacemakerArtificial heart valveFaintingVaricose veinsDeep leg painCold hands or feetAnemiaEasy bruising Respiratory Difficulty breathingChronic coughBronchitisEmphysemaAsthmaWheezingCoughing bloodPhlegm in throat Muscle, Bone & Joints Neck painBack painArthritisBursitisJoint pain or stiffnessArtificial jointMuscle painMuscle weakness Gastrointestinal NauseaVomitingVomiting bloodReflux or heartburnConstant hungerUlcerGall stonesConstipationsDiarrheaChronic laxative useRectal burning/painHemorrhoidsBlood in stool Neurological AnxietyDepressionIrritabilityEmotional problemsLoss of balancePoor memoryDizzinessSeizures/EpilepsyConcussionLack of coordinationExtremity numbnessExtremity tinglingParalysis Infections Strep throatMononucleosisTuberculosisHepatitisHIV/AIDS Urinary Frequent urinationUrgency to urinateIncontinencePain on urinationWake at night to urinateUrinary tract infectionBlood in urineKidney stones WELLNESS EVALUATION AUTHORIZATION AND RELEASE FORM This is to grant permission for a consultation and wellness evaluation and authorization to recommend. The evaluation may include recommendations for botanical remedies, stress reduction methods, manual therapies, acupuncture, homeopathic remedies, naturopathic therapies and/or nutritional changes designed to balance the pH, energy meridians and enhance overall wellness. These suggested remedies are not intended to replace any of the medications or treatments currently being provided or recommended by a primary care practitioner. I fully understand that the attending Naturopath is not an allopathic doctor (M.D.), but is a Board Certified Naturopathic Doctor providing services that are not allopathic, but that are within the parameters of a natural health, wellness philosophy, and traditional Naturopathy. I fully understand that the attending Naturopath does not offer allopathic drugs, surgery, chemical stimulants or radiation therapy, but is providing information and natural products to restore natural balance and optimum conditions for health and wellness based on the scope of his practice. I fully understand that the Naturopath is not diagnosing or treating any illness or disease, and that these services may not be generally accepted and/or recommended by allopathic physicians or other health professionals. I fully understand that the attending Naturopath is in no way encouraging me to terminate or modify any previous or on-going therapies under the direction of any licensed doctor, and I am not here for medical-diagnostic purposes or treatment procedures. I am not on this visit or any subsequent visit an agent for federal, state, or local agencies, or on a mission of entrapment or investigation. I presently seek consultation, advice, opinions and/or programs, tests, evaluations and/or products within the scope of the attending Naturopath’s wellness practice based upon the principles of natural health and have solicited the attending Naturopath’s services in good faith, exerting my free will and following the dictates of my own conscience, which allow me to select what I understand is more beneficial to my health. If I am accompanying a minor or an incompetent, I give full faith that I am legally and totally responsible for them. I authorize the attending Naturopath to provide his services to me on my behalf, and hereby release him from any and all claims and potential claims arising out of my actions or failure to act upon his advice. I give full faith that I have read and understand this document entirely. I hereby consent to and authorize the above-described evaluation and consultation: I have read and agree to the Wellness Evaluation Authorization and Release Form Date: Signature:
