Personal Information

Full Name*

Date of Birth

Email*

Phone

Address

Emergency Contact Name

Emergency Contact Phone

Chief Complaint & Symptoms

Primary Health Concern*

How long have you had these symptoms?

Previous Treatments or Diagnoses

Medications, Supplements & Allergies

Current Medications

Vitamins & Supplements

Allergies (medications, foods, environmental)

Medical History

Past Surgeries or Procedures

Hospitalizations

Family Medical History

Lifestyle & Wellness

Do you smoke or use tobacco?

YesNo

Alcohol UseSelect…NoneOccasional (1–2 drinks/week)Moderate (3–7 drinks/week)Heavy (8+ drinks/week)

Exercise FrequencySelect…Sedentary (little to none)Light (1–2 days/week)Moderate (3–4 days/week)Active (5+ days/week)

Sleep QualitySelect…PoorFairGoodExcellent

Stress LevelSelect…LowModerateHighVery High

Diet Description

Additional Notes

Anything else you'd like us to know?

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