Naturopathic Consult - Client Intake Forms
Intake Forms
Name / DateLike to be called by:
Mailing Address
City/State / Zip Code
Shipping Address
City/State / Zip Code
Phone (home) / Cell Phone
Emergency Contact: / Phone (home/cell)
Age / Date of Birth / Gender Female Male
Higher Education Level: / High School____ Under-Graduate____ Post-Graduate____
Occupation / Employer by
Referred by / Media: Please indicate source
Online (Google\Please list search words you used to find us
Health Care Organization
Friend or Family
Authorization to Provide Information; this health consultation is to provide you with alternative suggestion for healthcare only. It is up to you to make your own decision on what you will do for your health regarding testing, supplements and alternative care.
Signature:
Print Name:
Date:
This form provides a big picture to your health.
We understand that this is an extensive form. Get yourself a glass of water or tea, relax, and take your time.
If you could erase 3 problems, what would they be?
1.______
2
3.
When was the last time you felt well?
Did something trigger your change in health?
What makes you feel worse?
What makes you feel better?
PLEASE LIST CURRENT AND ONGOING PROBLEMS IN ORDER OF PRIORITY
Describe Problem / Mild / Mod. / Severe / Prior TreatmentApproach / Good / Fair / Bad
Example: Post Nasal drip / x / Elimination Diet / x
PAST MEDICAL HISTORY DIAGNOSIS/CONDITIONS/DISEASES
This is a list of any problems you might have had or have. Please Check appropriate box and provide date.
Gastrointestinal / DateIrritable Bowel / Genital and Urinary / Skin Diseases
Inflammatory Bowel / Kidney Stones / Eczema
GERD (Reflux) / Gout / Psoriasis
Peptic Ulcer / Urinary Infections / Melanoma
Celiac Disease / Yeast Infections / Neurologic/Mood
Gall Bladder / Erectile/Sexual Issues / Depression
Cardiovascular / Musculoskeletal/Pain / Anxiety
Heart Attack / Osteoarthritis / Bipolar Disorder
Elevated Cholesterol / Osteoporosis / Schizophrenia
Arrhythmia / Osteopenia / Memory Issues
Hypertension / Chronic Pain / Injuries
Mitral Valve Prolapse / Inflammatory/Autoimmune / Head Injury
Endocrine / Chronic Fatigue / Neck Injury
Type 1 or 2 Diabetes / Autoimmune Disease / Back Injury
Pre-Diabetes / Food Allergies / Knee Injury
Hypoglycemia / Chemical Sensitivities / Ankle Injury
Hypothyroidism / Poor Immune Function / Car Accident
Hyperthyroidism / Herpes-Genital / Surgeries
Polycystic Ovarian / Respiratory Disease / Appendectomy
Weight Gain / Asthma / Hysterectomy
Weight Loss / Chronic Sinusitis / Gall Bladder
Eating Disorder / Bronchitis / Hernia
Skin Diseases / Pneumonia / Dental Surgery
Eczema / Sleep Apnea / Joint replacement
Psoriasis / Heart Surgery
Melanoma / Other / Cancer
Explain: / Explain:
Dr. Keri Brown, N.D. Wide Awake Wellness 970-889-3541
Naturopathic Consult - Client Intake Forms
Full Physical Exam / Upper Endoscopy
Bone Density / Upper GI Series
Colonoscopy / Hemoccult (stool/blood) Test
Blood Chemistry Panel / Other:
Dr. Keri Brown, N.D. Wide Awake Wellness 970-889-3541
Naturopathic Consult - Client Intake Forms
A / B / AB / O / Rh / Rh+ / Unknown
Height (feet/inches) / Current weight
Usual weight range +/- 5 lbs. / Desired weight range +/- 5 lbs
Highest adult weight / Lowest adult weight
Weight fluctuations (>10 lbs.)
Hospitalization
If yes, list Date / Reason
Dr. Keri Brown, N.D. Wide Awake Wellness 970-889-3541
Naturopathic Consult - Client Intake Forms
Silver Mercury Fillings / If yes, how many / Tooth Pain
Removal of Mercury / When, how many / Bleeding Gums
Root Canals / If yes, how many / Loose Teeth
Implants / Grinding Teeth
Gingivitis / Other:
Dr. Keri Brown, N.D. Wide Awake Wellness 970-889-3541
Naturopathic Consult - Client Intake Forms
CURRENT MEDICAL HISTORY
MEDICATIONSNutritional Supplements (Vitamins/Minerals/Herbs/Homeopathic)
Supplement & Brand / Dose / Frequency / Start date (mo./yr.) / Reason for Use
Current Medications
Medication / Dose / Frequency / Start date (mo./yr.) / Reason for Use
MEDICATIONS (Continue) / YES / NO
Have your medications or supplements ever caused you unusual side effects or problems?
Have you had prolonged or regular use of NSAIDS (Advil, Aleve, etc.), Motrin, Aspirin?
Have you had prolonged or regular use of Acid Blocking Drugs (Tagamet, Zantac, Prilosec)
Frequent Antibiotic >2 times a year or long term?
Environmental and Detoxification Assessment / YES / NO
Do you have known significant reactions or sensitivities
Cigarette Smoke / Perfumed/
Colognes / Auto Fumes / Mold / Electromagnetic Radiation / Other:
Do you have an adverse reaction to caffeine
Do you have a known history of significant exposure to any harmful chemicals?
Herbicides / Pesticides / Organic Solvents / Heavy Metals / Insecticides
Other:
Sleep
Average number of hours you sleep per night / 3-4 hr. / 4-6 hr. / 6-9 hr.
Do you sleep well? / Yes / No
Do you have trouble falling asleep / Yes / No
Do you wake up at night?What Time? / 11pm-1am / 1am-3am / 3am-5am / 5am-7am
What is your best time of day / 8-11 am / 12-4 pm / 4-8 pm / 8-11 pm
What is your worst time of day / 8-11 am / 12-4 pm / 4-8 pm / 8-11 pm
Do you use sleeping aids / Yes / No / Explain:
Do you have problems with insomnia / Yes / No
Do you awake rested / Yes / No
Exercise: Activity Type / Frequency per week / Duration of minuets
Nutrition History
Do you currently follow a specific diet or nutritional program / Yes / No
Check all that apply:
Low fat / No Dairy / Low Carbohydrates / High Protein / Low Sodium
Diabetic / No Wheat / Gluten restricted / Vegetarian / Vegan
Known food allergies: / Wheat / Dairy / Corn / Citrus / Egg / Alcohol
Do you have any immediate symptoms in associations with eating / Yes / No
If yes, Check all that apply:
Belching / Bloating / Abdominal pain / Diarrhea / Hives / Post Nasal Drip
Do fatty foods cause indigestion / Yes / No
Does skipping a meal greatly affect you / Yes / No
Do you have delayed symptoms to eating certain foods (up to 24/48 hours) / Yes / No
How often do you eat / How many times a day
Are you thirsty / Yes / No
Dr. Keri Brown, N.D. Wide Awake Wellness 970-889-3541
Naturopathic Consult - Client Intake Forms
Do you have bowel movement daily / Yes / No
Frequent diarrhea / Yes / No
If yes, are they explosive / Yes / No / How many times a day?
Constipated often / Yes / No
If yes, how many days between
Do you have intestinal gas / Yes / No
Offensive odor / Yes / No / Occasionally / Daily / Excessive
Difficult to pass / Yes / No
Are they: / Hard / Hard small balls / Watery / Loose / Thin / Float
Do you have stomach or abdominal pain / Yes / No
What color is your stool / Grey / Light Tan / Brown / Black
Do you ever see blood in the stools / Yes / No
Dr. Keri Brown, N.D. Wide Awake Wellness 970-889-3541
Naturopathic Consult - Client Intake Forms
Do you have an excessive amount of stress in your life / Yes / No
Do you feel you can easily handle the stress in your life / Yes / No
Daily Stressors / Work / Family / Social / Finances / Health
Do you practice relaxation techniques or meditation / Yes / No
Yoga / Mediation / Imagery / Breathing / Tia Chi / Prayer
Have you ever been abused, a victim of a crime or experienced a significant trauma / Yes / No
Dr. Keri Brown, N.D. Wide Awake Wellness 970-889-3541
Naturopathic Consult - Client Intake Forms
Do you feel significantly less vital than you did a year ago / Yes / No
Are you happy / Yes / No
Do you believe stress is presently reducing the quality of your life / Yes / No
Do you experience any of the following? / Yes / No
Over-sympathetic: sense of despair, disgust, nervousness / Yes / No
Low self-esteem: hopelessness, worries, distrust, live through others / Yes / No
Rigidly positioned: defensive, crying, compelled to neatness / Yes / No
Experiencing grief: sadness, anguish, yearning, cloudy thinking / Yes / No
Fear: Bad memory, contemplated, impending doom, dread / Yes / No
Resentment: emotionally repressed, depression. Indecisive, galled, stubborn / Yes / No
Anger: aggression, irritability, frustration / Yes / No
Lost, vulnerable: insecurities, abandoned, absent mindedness, deserted / Yes / No
Frightfully overjoyed: lack of emotions, rapid mannerisms and speech, talkative, abnormal laughter (inappropriate) / Yes / No
Muddled instability: lack of emotions, up and down, can’t figure it out, paranoia, mudded thinking / Yes / No
Non-thinking, non-emotions: sluggish memory, vivid dreaming, depleted, suppressed / Yes / No
Memory Screening
Forgetting where you have put something, losing things around the house / Yes / No
Failing to recognize places that you have been before / Yes / No
Finding a television story difficult to follow / Yes / No
Not remembering a change in your daily routine / Yes / No
Having to go back to check whether you have done something that you meant to do / Yes / No
Completely forgetting to take things with you, having to go back and fetch them / Yes / No
Forgetting that you were told something yesterday or a few days ago / Yes / No
Starting to read something without realizing you have already read it before / Yes / No
Having difficulty picking up a new skill, for example new game or new gadget / Yes / No
Finding that a word is “on the tip of your tongue,” but you can’t quite find it / Yes / No
Forgetting details of what you did or what happened the day before / Yes / No
When talking to someone, forgetting what you said “What was I talking about?” / Yes / No
Dr. Keri Brown, N.D. Wide Awake Wellness 970-889-3541
Naturopathic Consult - Client Intake Forms
Family History
Please indicate if any family member has had and/or died from any of the following: (Relationship & Age)
Self / Mother / Father / Sisters / Brothers / Children / Gndparent (Mother’s) / Gndparent (Father’s) / Aunt/UncleAlcoholism
Allergies
Asthma
Inflammatory Arthritis
Inflammatory Bowel
Cancer
Breast Cancer
Diabetes
Eczema / Psoriasis
Genetic Disease
Glaucoma
Heart Disease
High Cholesterol
Immune Disorder
High Blood Pressure
Kidney Disease
Mental / Nervous d/o
Osteoporosis
Parkinson’s
Depression
Schizophrenia
Bipolar Disorder
Stomach Ulcers
Stroke
Thyroid Disorders
SYMPTOM SURVEY FORM
Leave Blank in NO symptoms / 52 / Awaken few hours’ sleep – hard to get back to sleep
X / MILD symptoms (occurred once or twice in last 6 months) / 53 / Craves candy or coffee in afternoon
X / MODERATE symptoms (occurred once or twice last month) / 54 / Moods of depression – ‘blues’
X / SEVERE symptoms (chronic, occurred once or twice last week) / 55 / Abnormal craving for sweets or snacks
GROUP 1 / GROUP 4
2 / Get chilled often / 56 / Hands and feet go to sleep easily
3 / “Lump” in throat / 57 / Sigh frequently, ‘air under’
5 / Pulse speeds after meals / 58 / High altitude discomfort
6 / Keyed up – fail to calm / 60 / Opens windows in closed rooms
7 / Cut heals slowly / 61 / Susceptible to colds and fevers
8 / Gag easily / 62 / Afternoon ‘yawner’
9 / Unable to relax, startles easily / 63 / Get “Drowsy” often
10 / Extremities cold, clammy / 64 / Swollen ankles, worse at night
11 / Strong light irritates / 65 / Muscle cramps, worse exercise; ‘charley horses’
12 / Urine amount reduced / 66 / Shortness of breath on exertion
13 / Heart pounds after retiring / 67 / Dull pain in chest or radiation, worse on exertion
14 / “Nervous” stomach / 68 / Bruise easily, ‘black and blue’ spots
15 / Appetite reduced / 70 / ‘Nose bleeds’ frequently
16 / Cold sweats often / 71 / Noises in head, or ‘ringing in ears’
17 / Fever easily raised / 72 / Tension under breastbone, ‘tightness’ worse exertion
18 / Skin sensitive to touch / GROUP 5
19 / Staring, blinks little / 73 / Dizziness
20 / Sour stomach often / 74 / Dry skin
GROUP 2 / 75 / Burning Feet
21 / Joint stiffness on arising / 76 / Blurred vision
22 / Muscle-leg-toe cramps at night / 77 / Itching skin and feet
23 / “Butterfly” stomach, cramps / 79 / Frequent skin rashes
25 / Eyes blink often / 80 / Bitter, metallic taste in mouth in morning
24 / Eyes or nose watery / 81 / Bowel movement painful or difficult
26 / Eyelids swollen, puffy / 82 / Worrier feels insecure
27 / Indigestion soon after eating / 83 / Feels queasy; headache over eyes
28 / Always seems hungry; “lightheaded” often / 84 / Greasy food upset
29 / Digestion rapid / 85 / Stools light colored
30 / Vomiting frequent / 86 / Skin peels on foot soles
31 / Hoarseness frequent / 87 / Pain between shoulder blades
32 / Breathing irregular / 88 / Use laxatives
33 / Pulse slow; feels “irregular” / 89 / Stools alternating from soft to watery
34 / Gagging reflex slow / 90 / History of gallbladder attach sot gallstones
35 / Difficulty swallowing / 91 / Sneezing attacks
36 / Constipation, diarrhea alternation / 92 / Dreaming, nightmares type bad dreams
37 / ‘Slow starter’ / 93 / Bad breath (halitosis)
38 / Gets ‘chilled’ infrequently / 94 / Milk products causes distress
39 / Perspire easily / 95 / Sensitivity to hot water
40 / Circulation poor, sensitive to cold / 96 / Burning or itching anus
41 / Subject to colds, asthma, bronchitis / 97 / Craves sweets
GROUP 3 / GROUP 6
42 / Eat when nervous / 98 / Loss of taste for meat
43 / Excessive appetite / 99 / Lower bowel gas several hours after eating
44 / Hungry between meals / 100 / Burning stomach sensation, eating relieves
45 / Irritable before meals / 101 / Coated tongue
46 / Get ‘shaky’ if hungry / 102 / Pass large amounts of foul-smelling gas
47 / Fatigue, eating relieves / 103 / Indigestion ½-1 hours after eating; up to 3-4 hours
48 / ’Lightheaded’ if meals delayed / 105 / Gas shortly after eating
49 / Heart palpated if meals missed or delayed / 106 / Stomach ‘bloated’ after eating
51 / Overeating sweets upsets
pg. 1
Dr. Keri Brown, N.D. Wide Awake Wellness 970-889-3541
Naturopathic Consult - Client Intake Forms
107 / Insomnia / 161 / Tendency to hives
108 / Nervousness / 162 / Arthritis tendencies
109 / Can’t gain weight / 163 / Perspiration increases
110 / Intolerance to heat / 164 / Bowel disorder
111 / Highly emotional / 165 / Poor circulation
112 / Flushes easily / 166 / Swollen ankles
113 / Night sweats / 167 / Craves salt
114 / Thin, moist skin / 168 / Brown spots or bronzing of skin
115 / Inward trembling / 169 / Allergies – tendency to asthma
116 / Heart palpitates / 170 / Weakness after colds, influenza
117 / Increased appetite without weight gain / 171 / Exhaustion – muscular and nervous
118 / Pulse fast at rest / 172 / Respiratory disorders
119 / Eyelids and face twitch / GROUP 8
GROUP 7B / 173 / Apprehension
122 / Increased weight gain / 174 / Irritability
123 / Decreased in appetite / 175 / Morbid fears
124 / Fatigue easily / 176 / Never seems to get well
125 / Ringing in ears / 177 / Forgetfulness
126 / Sleepy during the day / 180 / Craving for sweets
127 / Sensitive to cold / 181 / Muscular soreness
128 / Dry or scaly skin / 182 / Depression, feeling of dread
129 / Constipation / 183 / Noise sensitivity
130 / Mental sluggishness / 184 / Acoustic hallucinations
131 / Hair course falls out / 179 / Poor appetite
132 / Headaches upon arising, wear off during the day / 185 / Tendency to cry without reason
133 / Slow pulse, below 55 / 186 / Hair is course and/or thinning
134 / Frequency of urination / 187 / Weakness
135 / Impaired hearing / 189 / Skin sensitive to touch
136 / Reduced initiative / 190 / Tendency towards hives
GROUP 7C / 191 / Nervousness
137 / Failing memory / 192 / Headaches
138 / Low blood pressure / 193 / Insomnia
139 / Increased sex drive / 194 / Anxiety
140 / Headaches, ‘splitting or rending’ type / 196 / Inability to concentrate, confusion
141 / Decreased sugar tolerance / 197 / Frequent stuffy nose, sinus infection
GROUP 7D / 199 / Loose joints
142 / Abnormal thirst / FEMALE ONLY
143 / Bloating of abdomen / 203 / Depressed feeling before menstruation
144 / Weight gain around hips or waist / 204 / Menstruation excessive and prolonged
145 / Sex drive reduced or lacking / 205 / Painful breasts
146 / Tendency to ulcers, colitis / 200 / Very easily fatigues
147 / Increased sugar tolerance / 201 / Premenstrual tension
148 / Women: menstrual disorder / 202 / Painful menses
149 / Young girls: lack of menstrual function / 208 / Hysterectomy / ovaries removed
GROUP 7E / 209 / Menopausal hot flashes
150 / Dizziness / 210 / Menses scanty or misses
151 / Headaches / 211 / Acne, worse at menses
152 / Hot flashes / 212 / Depression of long standing
153 / Increased blood pressure / 206 / Menstruate too frequently
154 / Hair growth on face and body (female) / 207 / Vaginal discharge
155 / Sugar in urine (not diabetes) / MALE ONLY
156 / Masculine tendencies (female) / 213 / Prostate trouble
GROUP 7F / 214 / Urination difficult or dribbling or Night urination
157 / Weakness, dizziness / 218 / Pain on inside of legs or heels
158 / Chronic fatigue / 219 / Lack of energy or Tire too easily(221)
159 / Low blood pressure / 220 / Migration aches and pains or Legs nervousness night
Please write down any other information you deem necessary for Dr. Brown too know.
pg. 1
Dr. Keri Brown, N.D. Wide Awake Wellness 970-889-3541