Name:

Birth Date:

Address:

Phone:

Mobile:

Email:

Gender: Male Female (circle one)

Marital Status: Single Married Divorced Defacto Widow

Occupation

Medical Doctor:

Date of last physical exam:

Blood tests done? Y N

Emergency Contact

Name:

Relation to you:

Phone:

How did you find out about the clinic?

General Intake

What is your main reason for seeing Shanie Ruprai-ND?

What are your treatment goals & expectations?

How would you rate your overall health? Poor Fair Good Excellent

(please circle all that apply)

How committed are you in taking responsibility for your healing & following through on treatment?

(please circle that apply)

(Low) 0 1 2 3 4 5 6 7 8 9 10 (High)

What kind of conventional treatment have you received?

Have you ever seen a: (please choose all that apply)

Naturopathic Doctor Chiropractor Acupuncturist Massage Therapist Osteopath Other?

Current Medications (please list dosage)

1.

2.

3.

4.

5.

Nutritional Supplements (please list dosage)

1.

2.

3.

4.

5.

Are you currently working with a professional counselor, psychologist, social worker or therapist? Y N

Have you in the past? Y N

When?

Do you have any specific allergies? Y N

Please List:

Have you had any major injuries? Y N

If yes, please explain:

Have you had previous surgeries or hospitalizations? Y N

If yes, please explain: (include dates if known):

In your opinion, what is your weakest system (e.g. digestive, immune, cardiovascular, etc.)?

Vaccination

Have you been vaccinated? Y N

Any adverse reactions?

Other Activities

Which of the following do you currently use? (please list how much, how often)

Alcohol

Tobacco

Coffee

Hormones

Laxatives

Sedatives

Antacids

Cortisone

Recreational drugs (please specify)

What do you enjoy most in life?

What are your main interests and hobbies?

What do you worry most about in life?

What nurtures you?

Do you have a religious/spiritual practice?

Do you exercise? Y N If so, what do you do?

How would you rate the quality of your sleep?

Do you have troubles falling or staying asleep?

How many hours of sleep do you get per night?

How many do you feel you need?

Do you nap or rest during the day?

How would you describe your energy?

Are you sexually active? Y N

Are you experiencing a loss in sexual desire? Y N

Do you use birth control? Y N

If so, what form?

Digestion

How would you describe your digestion?

How frequently do you have a bowel movement?

Any history of:(tick all that apply)

Gas

Bloating

Diarrhea

Constipation

Blood in stool

Undigested food

Black stools

Strong odor

Musculoskeletal

Do you have muscle aches and pains? Y N

If so, where?

Do you have joint aches and pains? Y N

If so, where?

Does this interfere with your daily activity? Y N

Is this due to an accident/injury? Y N

Environment

Is your home damp or moldy? Y N

Do you have specialized air filtration at home? Y N

Do you live/work in the city? Y N

Do you work in an office building? Y N

Do the windows open? Y N

Are you exposed to toxic materials? Y N

Do you smoke or are you exposed to second hand smoke? Y N

What do you use as drinking water?

Tap Bottled Filtered Reverse osmosis:

Is there anything else you feel I should know?

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