Get Started Name * First Name Last Name Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Birthday * MM DD YYYY Gender * Male Female Other Marital Status * Single Married Domestic Partner Divorced Other Emergency Contact Information Emergency Contact Name * First Name Last Name Emergency Contact Relationship * Emergency Contact Phone * (###) ### #### Health Information Height * Weight * Purpose of Visit * General Preventative Medicine Hormonal Balance Women's Health Men's Health Digestive Health Detoxification Other What are your medical goals? List any allergies you may have. List any past medications. List any chronic medical conditions you may have. Share any relevant family medical history. (Women) List any gynecological concerns you may have. Lifestyle & Habits Do you exercise regularly? Yes No How would you describe your dietary preferences? How would you describe your sleep quality? What are the most significant stressors in your life? What brings joy to your life? What have you tried doing to improve your health? Consent & Authorization I authorize the release of my medical information to my insurance provider and other healthcare professionals involved in my care. * Yes I consent to receive communication via phone, email, or text regarding my appointments and medical care. * Yes I understand that naturopathic medicine involves a holistic approach to health and may include lifestyle and dietary recommendations, herbal remedies, and nutritional therapies. * Yes By typing your name below, you certify that all information provided is accurate and complete to the best of your knowledge. * First Name Last Name Who can we thank for your referral? Thank you!
