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Services
Remedies Store
Homeo-care
About Us
Contact Us

Name*

Age*

Date of Birth*

Gender*

Male

Female

Other

Address*

Country*

United States

Canada

India

Other

Country (If Other)

Your Email*

Contact Number*

Emergency Contact*

Relationship with Emergency Contact*

Phone Number*

Medical Doctor

Phone Number

Address

How did you hear about us?*

Health Goals/Concerns: What main health goals/concerns brought you to the clinic today?*

For how long have you had it?*

Can you trace the origin of your illness? (i.e. shock, worry, diet, over exertion, accident)

Previous practitioners consulted for this condition: MD/ ND/ Other*

Please explain your diagnosis, therapy and results where applicable:*

What types of therapy have you tried for this problem?*

Diet modification Vitamin/mineral supplements Herbs Homeopathy Chiropractor Acupuncture Conventional drugs Osteopathy Other*

What makes it better?*

What makes it worse?*

Please list any other health concerns or goals in order of importance*

Occupation*

Do you work in Shifts?

Yes

No

Do you enjoy your work?

Yes

No

Sometimes

Hours/day you spend

Work Duration*

Watching TV*

Driving*

In front of computer/screen*

On a scale of 1 to 10, 1 being the lowest and 10 being the highest, what is the level of stress you are presently experiencing in your life?*

Please list the major causes of stress for you (work, finances, relationship, health, etc.)*

Have you experienced any major trauma, loss, or life changing significant events?*

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

Any history of Hospitalization /Surgery/Injury?*

Yes

No

Any Allergies and/or food sensitivities?*

Yes

No

if yes, kindly share the Allergies and/or food sensitivities.

Current medications/supplements: Please list ALL medications or supplements you take on a regular basis: Medication/Supplement Dose (if known) Length of Use Prescribing Practitioner Are You Taking Presently?*

Date of last complete physical exam*

Have you taken antibiotics within the last 5 years?

Yes

No

If yes, how many times?

Were you frequently given antibiotics as a child?*

Yes

No

if yes, how often?

Have you been vaccinated? If so, what vaccines have you received?

Do you have any allergies?

Diet and Health Habits:

General energy level out of 10 (1=lowest, 10=highest)*

What time of day is it highest?*

What time of day is it lowest?*

Are you on a special diet?*

Yes

No

if yes, please explain

Do you crave?*

Sugur

Chocolate

Salt

Protein

Fats

Sour

Other

If other, please specify foods

Do you feel thirsty?*

Yes

No

How many glasses of water do you drink on an average day?

What temperature of beverages do you prefer?*

Cold

Room Temprature

Hot

How is your digestion?*

Do you experience?*

Bloating

Gas

Diarrhea

Constipation

Please check which of the following substances you are currently using? (If Applicable)

Please check which of the following substances you are currently using? (If Applicable)*

Alcohol

Laxative/Purgatives

Chewing or smoking Tobacco

Pain Killers

Recreational Drugs

Coffee

Exercise

if yes, how much?

Alcohol

Laxative/Purgatives

Chewing or smoking Tobacco

Pain Killers

Recreational Drugs

Coffee

Exercise

How many hours of sleep do you get each night?*

Do you wake up feeling rested?*

Yes

No

Do you wake up in the night?*

Yes

No

Do you take Nap?*

Yes

No

How long does it take to fall back asleep?*

Have you ever been diagnosed with any of the following?*

Any relevant family history of medical disease? Explain.*

Please list any other illnesses of your relatives, such as: parents, siblings, grandparents, aunts and uncles*

Is there anything else that you feel is important that hasn’t been addressed on this form?*

PATIENT INTAKE FORM

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