New Patient Intake Form

Confidential New Patient Information
Please fill out the following forms and submit them to our office at least 2 days before your first appointment.

We recommend filling these forms out in one sitting as there's not a reliable way to save and come back to an incomplete submission. Allow for 20-30 minutes to complete the entire new patient packet.

These forms are mobile-friendly, but you may find it more convenient to use a computer with a larger screen and a keyboard.

Thank you, and we look forward to providing you with excellence in naturopathic healthcare!
Today’s Date *

Month Day Year
Date
Patient’s Name *
Gender
Birthdate *

Month Day Year
Date
Age
Race/Ethnicity
Street Address *
City *
State *
Zip *
Primary Phone *
Alternate Phone
Email address *
example@example.com
Alternate Email
example@example.com
Relationship Status (i.e. single, married, divorced)
Spouse/Partner’s Name and Occupation
Children (Names/Ages)
Parent/Guardian Name (if patient under 18)
Occupation
Employer
Hobbies/Interests
Emergency Contact
Name
Relationship
Phone
Primary Care Physician
Your Doctor's Name
Office Phone
How did you hear about us?

Referred by an existing patient Referred by a healthcare provider Internet Search Other
If you were referred by someone, please share their name:
If you were referred by someone, may we have your permission to thank the individual?

Yes, please! Yes, but please keep my name anonymous No
What made you decide to make an appointment with Lewis Family Natural Health?

List, in order of importance, your major health concerns/what you wish us to address today:
1.
2.
3.
4.
5.
What treatments or therapies have you already tried? How have they worked for you?

Current Medications: (include all prescription and over-the-counter medications; don’t forget birth control, hormones, etc.)

	Medication	Dose/Frequency	For how long?	For what reason?

Current Supplements: (include all vitamins, herbs, homeopathy, or other supplements)

	Supplement	Brand	Dose/Frequency	For how long?	For what reason?

Please list your current health care professionals:

	Doctor/Practitioner	Specialty	Office Name	Office Phone Number

Please write down a general timeline of your health history. Starting from childhood, include all major illnesses, injuries, operations, hospitalizations, and other medical diagnoses.

	Illness/Operation/Hospitalization/Injury/Diagnoses:	Year	Details/Notes

Have you had any recent lab tests or blood work? What kind, when, and what were the overall results? Please provide a summary below. (There will also be an opportunity at the end of this form to upload any labs or other medical records that you have access to, so you do not need to detail the exact results here.)
Have you had Covid-19 or been vaccinated for Covid-19? If you've had it, please describe your experience, including when you were diagnosed, what symptoms you experienced, and if you still have any remaining symptoms. If you are vaccinated, please share which vaccine you had, if you completed both shots (if you received a two-shot vaccine), and the date(s) you were vaccinated. You may also share any additional information regarding Covid-19 here.
Family History: Has anyone in your immediate family (parents, siblings, children) ever had heart disease, cancer, autoimmune disease, thyroid problems, or any other notable medical conditions? If so, please describe.
Please list any known allergies (Medications, Foods, Environmental, Chemical)

The following sections are related to gender. Which section would you like to see next?

I would like to answer the questions about men's health. I would like to answer the questions about women's health. I would like to answer questions from both sections.

How may we best be of service to you? Do you have any specific wishes or requests regarding your treatment that you would like us to know about? Are there religious, spiritual, or cultural considerations you would like to share with us?
Thank you for filling out this intake form! We really appreciate this information and will use it to help provide you with the best naturopathic care at your upcoming appointment.

After submitting this form you will be given an opportunity on the next page to download a PDF copy of your answers for your own records.

You will also be directed to the next forms to be completed, including our Informed Consent Forms. You will also have a chance to upload any records you may have from other healthcare practitioners.

Please hit "SUBMIT" to save this form and continue to the next steps.
Should be Empty:

	PAST	CURRENT
Birth Control Pill, Patch, or Ring
Injectable or Implanted Hormone
Condoms
Diaphragm, cervical cap, foam/gel
Sterilization "Tubes Tied"
Male partner had vasectomy
IUD
Natural family planning/rhythm method
Other

Confidential New Patient Information

Emergency Contact

Primary Care Physician

Review of Systems

MEN'S HEALTH SECTION:

When was your last:

WOMEN ONLY: Gynecological and Obstetrical History

Obstetrical History

Sexual History

Diet and Health Habits

Diet:

Exercise:

Weight:

Sleep:

Stress: