New Patient Intake Form
Dr.
Erika Kneeland, ND
Today's date:
Your name:
Date of Birth :
Phone:
Email:
Are you familiar
with naturopathic medicine?
How did you hear about our Clinic?
Main reason(s) for seeking
Naturopathic medical care.
Please indicate order of importance
and when symptoms first appeared.
Medical Doctor's name:
Do you consult with other health
care professionals? If so,
please list:
Please list medication/drugs you are
currently taking:
Please list all supplements you are
currently taking:
Do you
wear a medic alert bracelet?
(check
for yes)
Do you
have a pacemaker?
(check
for yes)
Do you
have any medication/drug related
allergies?
(check
for yes)
Do you
have any food/environmental
allergies or sensitivities?
(check
for yes)
For
Women: Date of
last PAP test?
(This screening is offered by Dr.
Kneeland)
Age of
first menstrual period?
If over
40, date of last mammogram?
Please check any of the following
conditions you have had:
Anemia
Arthritis
Are
there any conditions after which you
have never been totally well since,
or which have been more serious than
usual?
Please
list any operations,
hospitalizations, childbirths, major
accidents or traumas you have had:
Date:
Date:
Date:
Date:
Date:
Date:
Please indicate below which of the
following conditions have affected
your relatives: Indicate: F=Father, M=Mother,
S1=Sibling, S2=Sibling etc, PGM=Paternal
Grandmother, MGM=Maternal
Grandmother, PGF= Paternal
Grandfather, MGF= Maternal
Grandfather, PA=Paternal Aunt,
Do you
(check all that apply):
Have you
lost any weight recently?
no
yes
How many pounds?
What
exercise do you do and how much?
What are
your short-term health goals?
What are
your long-term health goals?
Extra Notes:
