Dr. Bradley (Insight Natural Medicine)
Patient Information
First Name *
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Last Name *
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Email Address: *
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Birthday (MM/DD/YYYY) *
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Address (address, city, state, zip code) *
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Phone number: *
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Are you a clinic employee, student or significant other of a student or staff?
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Are you a student at a university or college?
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Mother's name (minors only)
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Father's name (minors only)
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Emergency Contact (Name, phone number)
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Relationship to Emergency Contact:
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How did you hear about us?
What goals do you have for you visit at the clinic today?
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Have you ever consulted a Naturopathic physician, an Acupuncturist, a Nutrionist or a Counselor before?
Do you have any questions about our clinic or the care that you've chose for today?
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Please list any prescription medications that you are currently taking, with dosages:
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Please list any vitamins, herbs or homeopathic remedies that you are currently taking, with dosages:
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Please choose any of the folowing substances that you use regularly:
Do you have any particular diet regimens or restrictions? If yes, please describe:
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Do you exercise regularly? (Y/N) What type of exercise? How long? How often?
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Hospitalizations?
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Serious illnesses or injuries?
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Date of last physical/annual exam? (MM/DD/YYYY)
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Date of last blood tests? (MM/DD/YYYY)
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Personal and Family History: (Please check each box next to a conditon that applies to you or one of your family members)
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Do you have any children?
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