New Patient Intake Form Name * First Name Last Name Email * Date of Birth * MM DD YYYY Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Occupation Main presenting health concern: Please list any current medications and/or supplements (includes oral contraceptive pill) Are you currently pregnant or breastfeeding? Yes No Do you have any known allergies or intolerances? Yes No If yes, please type what these are below Current & Past Medical History Please list any relevant current or past medical conditions Asthma Anxiety Autoimmune disease Coeliac Disease Depression Diabetes Ear infection Eczema/Dermatitis/Psoriasis Endometriosis Glandular Fever/Epstein-Barr Virus Fibromyalgia Hepatitis HIV HPV Hypertension High cholesterol IBS IBD Previous Cancer Poly Cystic Ovarian Syndrome (PCOS) Thyroid disease Tonsilitis Urinary Tract Infections COVID-19 Other If other, please list below: PLEASE CHECK ANY RELEVANT SYMPTOMS: Digestion: Bloating Abdominal Pain Indigestion Reflux Constipation Diarrhoea Blood or Mucous in stools Discomfort/pain after fatty meals Nausea Weight loss or gain Musculoskeletal Back Pain Joint pain/stiffness Muscle Cramps Respiratory System Post-nasal drip Sinus congestion Wheezing Hayfever Chronic cough Female Health Infertility Perimenopause Menopause PMS with headaches, breast tenderness PMS with mood swings, depression PMS with acne PMS with pain Spotting/clots with period Irregular cycle Heavy periods Light periods Thrush Pain during sex Low libido Hot flushes General Health Fatigue Brain Fog Poor Memory Poor Concentration Poor would healing Headaches/Migraines Splitting nails White spots on nails Frequent Colds & Flus/Infections Please list any relevant family medical history How many hours of sleep on average do you get per night? What time do you wake up and go to bed? How would you rate your stress out of 10? (10 being high) How would you rate your energy out of 10 (10 being good) Do you drink alcohol? If so, how many standard drinks per week? Do you smoke or vape? Yes No Do you drink caffeinated beverages? Yes No If yes, what type of beverages? What time do you consume these and how many per day? How much water do you drink daily? Do you exercise? Yes No If yes, what type & how many days per week? Thank you for completing the intake form. I look forward to our consultation :)
