NATUROPATHIC ADULT INTAKE FORM

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G E N E R A L G. LUKE GONZALES, ND NATUROPATHIC ADULT INTAKE FORM 9 1 0 C A P I T O L S T N E S U I T E G, S A L E M, O R 9 7 3 0 1 P H O N E 9 7 1. 2 0 7. 3 6 8 0 FA X 5 0 3. 3 3 9. 9 5 8 5 L G O N Z A L E S N D @ G M A I L. C O M Name: Date of 1 s t Visit : Date of Birth : Address: City: Phone (home): Phone (cell): Oc c upa t i on: Age: Zip Code: Phone (work): Email: Gender: F M Hours worked per week: Marital Status: Single Common-law Same-Sex Married Separated Divorced Widowed Live with (check all that apply): Spouse Partner Parents Children Friends Alone Number of Children: Ages & Gender of children: E M E R G E N C Y C O N TA C T Name: Phone (home): Relationship: (work/cell): O T H E R H E A LT H C A R E P R O V I D E R S 1. 2. 3. 4. Do you have regular screening tests done by another doctor? (Pap, annual physical, bloodwork, etc) yes no Date of last physical exam: 1

How did you hear about our clinic? G. LUKE GONZALES, ND H E A LT H C O N C E R N S Reason for visit (list in order of importance): How long have you had this condition: What type of therapies have you tried in the past for these concern(s)? Diet Modification Vitamins/minerals Detoxification Herbs Homeopathy Chiropractic Acupuncture Pharmaceuticals Other _ What was the outcome? FA M I LY H I S T O R Y Please check any the following that a family member has experienced: Arthritis Diabetes Psoriasis Asthma Eczema Kidney Disease Alzheimer s Disease Drug Addiction/Alcoholism Stroke Autoimmune (MS, Lupus, etc) Heart disease Thyroid Issues Cancer High Blood Pressure Mental Illness Depression Migraine headaches Other H E A LT H H I S T O R Y How would you rate your general current state of health on the following scale: 1 2 3 4 5 6 7 8 9 10 Current prescription(s) and/or over the counter medication(s): Current supplements and/or vitamins: Major Hospitalizations, Surgeries, and Injuries: please indicate dates and complications (if any) 2

Year Illness, Surgery, Injury, Major Medical Diagnosis Do you have any allergies (foods, medications, environmental, etc.) Do you frequently use any of the following: Aspirin Antacids Birth control Laxatives Diet pills Tylenol/Advil/Ibuprofen Alcohol Type and amount per day/week: Tobacco Form and amount/day: Caffeine Form and amount/day Recreational drugs What and how often: Please check all of the following that apply to you: EXERCISE NUTRITION & DIET FOOD FREQUENCY SLEEP No formal exercise Mixed food diet (animal Skip Breakfast Wake feeling rested and vegetable) 5-7 days per week Vegetarian One meal per day Wake feeling tired 3-4 days per week Vegan Two meals per day 8-10 hours per night 1-2 days per week Salt restriction Three meals per day 6-8 hours per night 45 minutes or more duration per workout Fat Restriction Graze (small frequent meals) Less than 6 hours per night 30-45 minutes duration per Carbohydrate Restriction Eat constantly whether Undisturbed sleep workout hungry or not less than 30 minutes duration per workout Religious restriction(s) Eat on the run Difficulty falling asleep Walk Food intolerances Add salt to food Difficulty staying asleep Run, jog, jump rope Other _ Weight train Yoga Swim Other Please rate your quality of sleep on the following scale (1 being the least): 12345678910 Please rate your current stress level on the following scale (1 being the least):

12345678910 Source: _ Have you experienced any unintentional weight loss of 10 lbs or more over the last 3 months? Yes No Are you exposed to any harmful chemicals (e.g. smoke, renovations, pesticides)? Yes No If so, please describe. Is there anything else you feel is important to add: P E R S O N A L O V E R V I E W Reversing illness by treating the underlying cause of disease, and effectively managing healthcare does not happen overnight. It requires a commitment to lifestyle change, and adherence to therapeutic protocols. What is the main condition or change you would like to see happen? How long do you feel this will take? How would you describe your present level of commitment to making changes in your health? Please circle one of the following. (%)0 102030405060708090100 What potential obstacles do you foresee in addressing the lifestyle factors that are undermining your health? Is there anything that will prevent you from adhering to the therapeutic protocols that I will be sharing with you? What expectations do you have of me as your Naturopathic Doctor? What three expectations do you have from this visit to our clinic? What long term expectations do you have from working with an ND? What do you love to do?

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