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Confidential Intake Form
Living Waters Naturopathic
Dr. Sandra Dean, ND MH CNHP
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* Indicates required question
Email
*
Your email
Last Name, First Name
*
Your answer
Address
*
Your answer
Phone
Your answer
Gender (Biological)
Female
Male
Other:
Clear selection
Birthdate
*
MM
/
DD
/
YYYY
Emergency Contact Name and Phone Number
*
Your answer
Emergency Contact Relationship
*
Your answer
PLace of Birth (City, Country)
*
Your answer
Marital Status
In a relationship
Married
Single
Seperated
Widowed
Other:
Clear selection
Number of Children
Your answer
Occupation
Your answer
Females: Are you menopausal or peri-menopausal?
Your answer
Females: When was your last period?
MM
/
DD
/
YYYY
Females: Do you currently use Hormone Replacement Therapy or Hormonally-Based Contraception?
No
Yes
Not currently, I have in the past
I am looking into this
Clear selection
Females: If Yes, How long?
Your answer
Females: Are you now nursing, pregnant or planning to become pregnant?
Yes
No
Clear selection
Males: Select any of the following issues in the past year:
Enlarged prostate or BPH.
Prostatitis
Erectile dysfunction
Male infertility
When were you last prescribed antibiotics?
Your answer
When is the last time you were vaccinated?
Your answer
Have you previously or are you currently scheduled to / receiving any of the COVID-19 vaccinations?
*
Yes
No
Have you had COVID-19?
Yes
No
Other:
Clear selection
If Yes, do you have any post-viral symptoms?
Your answer
Average daily energy level?
LOW
1
2
3
4
5
HIGH
Clear selection
Have you been diagnosed with any disease by a medical doctor? Please explain.
Your answer
List medications that you are currently taking.
Your answer
List Supplements taken daily.
Your answer
Have you had any surgeries? What was the date, and reason for surgery.
Your answer
What are your top three health concerns for this visit?
*
Your answer
Briefly describe what steps you have taken to address the above issues.
*
Your answer
On average how often do you drink water?
NEVER (<10 OZ / DAY)
OCCASIONALLY (10-40 OZ / DAY)
OFTEN (40-70 OZ / DAY)
ALWAYS DRINK AT LEAST HALF MY BODY WEIGHT IN OUNCES / DAY
Clear selection
What is the primary type of water that you drink?
TAP (CITY / MUNICIPALITY)
TAP (WELL)
FILTERED (R.O. / WHOLE HOUSE / BRITTA, ETC)
BOTTLED
Clear selection
How many times per week do you exercise? (elevated heart rate, and sweating)
NONE
1-2 X /WEEK
3 OR MORE TIMES A WEEK
Clear selection
What types of exercise do you do?
*
Your answer
Are you currently following a specific diet?
*
Your answer
Do you have any known food allergies?
*
Your answer
How many bowel movement eliminations per day?
*
Your answer
Check the foods you often consume on a daily basis.
*
Fried Foods
Dairy
Nicotine
Raw Vegetables
Eggs
Sugar
Meat
Fermented Food
Gluten
Processed foods
Artificial Sweeteners
Soda
Caffeine
Other:
Required
What do you crave?
*
SALTY
CHOCOLATES
SWEETS
BREADS
SOUR
SODA
ALCOHOL
Other:
Required
What are your favorite foods?
*
Your answer
Do you use any recreational drugs?
*
Yes
No
Occasionally
How many alcoholic drinks per week?
*
I don't drink at all
Only Socially
Less than 5 a week
Less than 10 a week
10 or more a week
How much time do you spend with family and friends?
*
NONE
LESS THAN 2 HOURS
2 - 5 HOURS WEEK
MORE THAN 5 HOURS
On average how many hours of sleep do you get per night?
*
LESS THAN 4 HOURS / NIGHT
MORE THAN 4, BUT LESS THAN 7 HOURS / NIGHT
BETWEEN 7 AND 9 HOURS / NIGHT
MORE THAN 9 HOURS / NIGHT
What time do you normally go to bed?
*
Time
:
AM
PM
Check any that apply
*
WAKE OFTEN AT NIGHT
HAVE TROUBLE FALLING ASLEEP
DON'T FEEL RESTED WHEN I WAKE IN THE MORNING
HAVE BREATHING ISSUES WHILE SLEEPING
I WAKE OFTEN TO USE THE BATHROOM
WHEN I WAKE, I CAN NOT FALL BACK TO SLEEP FOR A LONG WHILE
Other:
Required
How much daily stress (1 = Lowest 10 = Highest)
1
2
3
4
5
6
7
8
9
10
Clear selection
Do you feel pain upon waking up in the mornings? Explain.
*
Your answer
Are you currently experiencing any discomfort? Explain.
*
Your answer
If yes, please rate your discomfort.
MILD
1
2
3
4
5
SEVERE
Clear selection
What have you done or used to provide support/relief?
*
Your answer
Do you currently receive regular care from any of the following
*
Massage
Chiropractic
Acupuncture
Reflexology
Therapist/Counselor
Naturopathic
Primary Care Physician
Other:
Required
Describe your expectations for this visit
*
Your answer
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