Ahe4life.com

Alternative Health Empowerment, Inc.
670 Colonial Road, Suite 5
Memphis, Tennessee 38117
(901) 683-8200 /
Adult Naturopathic Intake Form

Personal Information
Name:__________________________________________ Age:_________ Birth Date:__________________ Sex: M □ F □ Address:_____________________________________________________________ City: ___________________________ State:______________________________ Postal Code: _______________ Telephone: (Home) _______________________ (Work) _______________________ (Cell) ________________________ Email: _________________________________________________ Occupation: ___________________________________ Employer: ______________________________________________ Marital Status: □Married □Single □Widowed □Divorced □Separated □Common-law Family Physician:________________________________________________________________________________________ Phone number:_________________________ Fax number: ____________________________ In case of emergency contact: ______________________________________________________________________________ Address:____________________________________________________ Phone number: ______________________________ Relationship: _________________________________________ How did you hear about the clinic? _________________________________________________________________________ Have you seen a Naturopathic Doctor before? □Yes □No If yes, for what ailment(s)? ________________________________________________________________________ Are any other members of your family seeing a Naturopath in this clinic? □Yes □No
Current History
What health concerns brought you in to the clinic today? 1. ______________________________________________ 3. ______________________________________________ 2. ______________________________________________ 4. ______________________________________________ Page 1 of 8 Adult Naturopathic Intake Form Has anything changed recently or become worse? _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Any religious affiliations or beliefs relevant to your health care and treatment? _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ What other therapies are you currently using? (Please check) □ Chiropractic □ Physiotherapy □ Massage Therapy □ Osteopathy □ Craniosacral Therapy □ Acupuncture □ Bowen Therapy □ Other________________________________ Please list all of your known allergies (medications, food, pollen, etc.): _______________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Medication and Supplement History
Please list all supplements, herbs and medications you are currently taking: Medication/Supplement
Page 2 of 8 Adult Naturopathic Intake Form For what condition(s):_______________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Health History
Please indicate which of the following conditions you have had: □Emphysema □Genital Herpes □Parasites Other (Please List)__________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Any conditions which have gotten progressively worse or from which you have not completely recovered? _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Page 3 of 8 Adult Naturopathic Intake Form Please indicate if you’ve had any hospitalizations, surgeries or serious injuries: Operation
Complications?
Long-term Effects?
WOMEN ONLY
Are you currently on the Birth Control Pill? □Yes □No Brand (Alesse, Ortho-Tricyclin etc.): __________________________________________ How long have you been on the Pill? __________________________________________ Age of first period: _______________ Last Menstrual Period: __________________________ Last Pap (date): _________________________ Last Breast Exam (date) _______________________ Bone Density Testing __________________________ Age at onset of menopause (if applicable): ______________________ Number of pregnancies? __________________ Number of live births? ___________________ Do you have difficulty with maintaining or achieving an erection? □Yes □No Last prostate exam: ______________________ PSA (blood test done) □Yes □No Diet and Lifestyle
Have you lost any weight lately? □Yes □No If yes, how many pounds? _____________________ Page 4 of 8 Adult Naturopathic Intake Form How much of the following substances do you use on a daily basis? Tobacco: _________________ Alcohol: _________________ Coffee: _________________ Soda Pop: _________________ Are there any foods or food groups that you avoid? □Yes □No If yes, which ones and why? _________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Food cravings: ____________________________________________________________________________________________ Do you consume dairy products? □Yes □No Do you choose organic food? □Yes □No What types? _____________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Do you consume freshwater fish? □Yes □No What types? __________________________________________________ Please indicate if you use any of the following: How often do you engage in physical activity? Daily______ 2-3 times/week______ once a week______ less than once a week______ What type of activities? _____________________________________________________________________________________ _________________________________________________________________________________________________________ On average, how many hours of sleep do you get per night? ___________________ Do you have interrupted sleep? □Yes □No Any dietary restrictions? (Religious or otherwise) ________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ How many glasses/ounces of water per day do you drink? ______________________________ What kind of water do you drink? □Distilled □Tap □Filtered tap water □Reverse Osmosis □Plastic bottled water □Glass bottled water □Ionized alkaline water Page 5 of 8 Adult Naturopathic Intake Form Digestion and Elimination
Digestion (check or fill in the answers)
Do you have any problems with gas, bloating or fullness after eating? □Yes □No How often? □Often □Sometimes □Never / How severe is it? □Mild □Moderate □Severe
Any heartburn? □Yes □No How often? _________________________________________________________________ Do you have gas in the upper or lower part of the abdomen or is it both areas? __________________________________________ How long have you had this problem? __________________________________________________________________________ How often do you have bowel movements? _____________________________________________________________________ Do you ever have any blood, mucus, undigested food or black stools (movements)? □Yes □No Do you have rectal itching? □Yes □No. Do your stools tend to be formed or loose? ________________________________ How often do you have diarrhea? _____________________________________________________________________________ Do you ever have alternating constipation and diarrhea? □Yes □No How often do you have thin, long and narrow stools? □Often □Sometimes □Never Do you ever have small and hard stools? □Often □Sometimes □Never Do your stools have a strong disagreeable odor? □Often □Sometimes □Never Have you ever fasted? □Yes □No Juice or water? ________________. How long did you fast? ____________________ How did you feel while you were fasting? _______________________________________________________________________ Have you traveled outside of the United States in the last 5 years? □Yes □No Camping in the past 5 years? □Yes □No Kidneys and Bladder
Have you had recurrent bladder infections? □Yes □No How were they treated? _____________________________________________________________________________________ How many bladder infections have you had in the last 3 years? ______________________________________________________ Do you have any burning sensation during or after urination? □Yes □No In the past ____ or present ____ Is your urine; □dark yellow □bright yellow □cloudy □pale or □clear? Does your urine have a strong odor to it? □Yes □No Do you have difficulty starting or stopping when urinating? □Yes □No Do you have difficulty perspiring? □Yes □No Do you perspire when you exercise? □Slightly □Moderately □Heavily Do you perspire at other times, other than when exercising? □Yes □No If yes, when: ___________________________________________________________________________________________ _________________________________________________________________________________________________________ Page 6 of 8 Adult Naturopathic Intake Form Does your perspiration have a strong odor? □Yes □No Does your temperature tend to run low ____ high ____ or average ____ compared to others? Occupational and Household
How long have you lived at your present address? ________________________________________________________________ Where have you lived previously? _____________________________________________________________________________ Please describe location, if old or new building, i.e., new construction, older construction, damp or moldy, etc. _________________________________________________________________________________________________________ Do you have specialized air filtration at home? □Yes □No Do you work in an office building? □Yes □No. Do the windows open? □Yes □No Do you work in the presence of toxic fumes or chemicals? □Yes □No Do any of your hobbies involve toxic materials? □Yes □No Are you currently exposed to second hand smoke? □Yes □No Do you have anything else you would like to comment on? ________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Family Health History
Please indicate each relevant condition for blood relatives only. □Emphysema □Genital Herpes □Parasites □Rheumatic Fever □Syphilis □Multiple Sclerosis Page 7 of 8 Adult Naturopathic Intake Form Any other condition(s) not listed: _____________________________________________________________________________ ________________________________________________________________________________________________________ Indicate which of the above conditions have affected your relatives: Family Member
Age (if alive)
Age at death
Condition
Page 8 of 8 Adult Naturopathic Intake Form

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