New Patient Intake Form - Adult | Naturopathic Doctor in Ottawa

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Gender
Date of Birth*
MM
DD
YYYY
Emergency Contact*
First Last
Relationship
Phone*
How did you hear about us?
- Revivelife Patient Referral
- Brochure, Business card
- Media (Radio, Newspaper, TV
- Social Media (Facebook, Twitter, LinkedIn)
- Workshop/Seminar
If referred by a friend or family member, what is their name?
Would you like to receive our newletters via email?*

PERSONAL HISTORY
HEIGHT WEIGHT WEIGHT GOAL WHEN WERE YOU LAST AT THIS GOAL WHAT IS YOUR AVERAGE ADULT WEIGHT?
One a scale of 1-10 (1 being low, 10 being high) How would you rate your energy level?
Marial Status
Sexual Preference
OCCUPATION
Average number of hours worked in a week
EDUCATION
Religious or Spiritual Beliefs
Hobbies
Do you have pets?
If so, what kind?
How much alcohol do you consume in a week?
How many cigarettes do you smoke in a week?
Have you smoked cigarettes in the past?
Are you exposed to second-hand smoke on a regular basis?
Do you use recreational drugs?
Please list your stressors and significant life events from most recent to last
How would you describe your emotional climate of your home?

TYPE OF EXERCISE	DURATION	INTENSITY (LIGHT, MODERATE, HEAVY)	FREQUENCY/WEEK

TYPE OF EXERCISE	DURATION	INTENSITY (LIGHT, MODERATE, HEAVY)	FREQUENCY/WEEK

TYPE OF EXERCISE	DURATION	INTENSITY (LIGHT, MODERATE, HEAVY)	FREQUENCY/WEEK

New Patient Intake Form – Adult

HEIGHT	WEIGHT	WEIGHT GOAL	WHEN WERE YOU LAST AT THIS GOAL	WHAT IS YOUR AVERAGE ADULT WEIGHT?