Naturopathic Medicine – Intake Form
Please complete the following form in order to provide us with the background information we
require to ensure you receive comprehensive care. It should take 15-20 minutes.
Contact Information:
YES I NO Can we send you our seasonal newsletter and monthly calendar of events via email.
Your email address will not be shared.

How did you hear about the Integrative Health Institute? (If another person, please provide name)
Care Co-ordination:
Medical Doctor
Please List any other Medical Providers:
Integrative Health Institute
46 Sherbourne Street, 2nd Floor I Toronto ON I M5A2P7 I 416.260.6038
Health Priorities / Chief Concerns:
List your main heath concerns (or reasons for visiting the clinic) in order of importance
1. ___________________________________________________________________________ 2. ___________________________________________________________________________ 3. ___________________________________________________________________________ 4. ___________________________________________________________________________ Medical History:
How would you describe your general state of health? (circle one) excellent good fair poor
Medical conditions: Please indicate any serious illnesses, conditions, or reasons for hospitalizations
Allergies or Food sensitivities: Please indicate any allergies and/or serious food sensitivities
Medications/Supplements: Please list all current medications/supplements
Integrative Health Institute
46 Sherbourne Street, 2nd Floor I Toronto ON I M5A2P7 I 416.260.6038
Past Medications/Supplements: Please list all past medications/supplements in the last 5 years.
Have you taken anti-biotics within the last 5 years (circle one)? Yes I No How many times have you taken anti-biotics within the last 5 years ____________ Were you frequently given anti-biotics as a child? ___________ Vaccinations: Please indicate which vaccinations you have received.
Do you use/have any of the following?
Integrative Health Institute
46 Sherbourne Street, 2nd Floor I Toronto ON I M5A2P7 I 416.260.6038
Screening Tests: Please indicate which of the following screening tests do you receive (if known)
Are you currently or could you be pregnant: Y I N How many weeks: _____ Have you ever been pregnant? Y I N How many times: _____ How many vaginal births: _____ C-Sections: _____How old were you when you had your first period: ____ Have your periods been regular: _____Have you taken/used (circle all that apply): The birth control pill/when:________ The patch/when:________ An IUD/when:________ Depo Provera injections/when:________ Other: ______________ Are you currently (circle one): Pre-menopausal I Transitioning through menopause I Post-menopausalHave you/are you, taking HRT: Y I N How long: _____ Integrative Health Institute
46 Sherbourne Street, 2nd Floor I Toronto ON I M5A2P7 I 416.260.6038
Family History:
Do you identify as: straight homosexual bi-sexual trans-gendered other: ___________________________
Do you have a strong emotional support network: Y I N Who: ________________________________________
Have you experienced any major trauma or loss in the past 5 years? __________________________________
Have you experienced any other trauma or loss in your life? __________________________________________
How would you currently rate your level of stress at this time? Minimal Average Considerable
What are the major causes of stress in your life at this time: (circle all that apply): financial career personal
marriage/relationship health family spiritual other (please elaborate):
How does your stress manifest itself: _____________________________________________________________
What type of coping mechanism to you employ to manage your stress? _______________________________
What do you do for exercise/movement? (Indicate type, frequency and time of day): _____________________________________________________________________________________________How many hours per night do you sleep: ______ nap: ______ Do you wake rested in the morning: Y I NWhat is your occupation: _________________________ Do you enjoy your work: Y I N I SometimesHow many hours per day do you spend on the following: Driving _____ Watching TV _____ Reading _____ In front of a computer _____ Work _____When was your last vacation: ___________________ Do you actively participate in a spiritual discipline (church, synagogue, meditation, etc…) Y I N Integrative Health Institute
46 Sherbourne Street, 2nd Floor I Toronto ON I M5A2P7 I 416.260.6038
Dietary Habits
What time of day do you eat the following: Breakfast: ______ Lunch: ______ Dinner: _____ Snacks: ______
Do you consume the following (circle all that apply and indicate frequency): Fresh Vegetables: ______ Fresh
Fruit: ______ Cold-water Fish: ______ Tuna: ______ canned goods: ______ Pop: ______ Milk: ______
Coffee: ______ Water: ______ Juice: ______ Processed Foods: ______ Microwavable meals: ______ Red
meat: ______ Cheese: ______ Chocolate: ______ Aspartame: ______ Deli meats: ______ Fast Food: ______
Do you crave (circle all that apply): Sugar I Chocolate I Salt I Crunchy food I Other: ______________________
Please provide examples of the following:
Breakfast: ___________________________________________________________________________________
Snack: ______________________________________________________________________________________
Lunch: ______________________________________________________________________________________
Snack: ______________________________________________________________________________________
Dinner: ______________________________________________________________________________________
Do you have regular bowel movements: Y I N Do you have to strain for a bowel movement: Y I N Do you
regularly have loose stools: Y I N Do you associate digestive difficulties with any particular foods: Y I N
Which foods: ________________________________________________________________________________
How many bowel movements do you have per day? ____________
Review of Systems
Please list conditions or concerns that involve the following systems:
SKIN (eg. eczema, psoriasis, hives, rashes) _______________________________________________________
HEAD (eg. headaches) _________________________________________________________________________
EYES (eg. itching, pain, infection, corrective lenses) ________________________________________________
EARS (eg. wax, discharge, hearing impairment) ____________________________________________________
NOSE (eg. sinus problems, pain, nose bleeds) _____________________________________________________
MOUTH (eg. difficult dentition, cavities, loss of taste, problems swallowing) _____________________________
NECK (eg. stiffness, tenderness, hoarseness, tonsillitis, swelling) ______________________________________
HEART (eg. rheumatic fever, murmurs, chest pain) __________________________________________________
LUNGS (eg. cough, asthma, wheezing) ___________________________________________________________
GASTROINTESTINAL (eg. vomiting, swallowing, diarrhea, constipation) ________________________________
URINARY (eg. pain, increased frequency, blood) ___________________________________________________
MALE (eg. hernias, pain or masses in scrotum/testes) _______________________________________________
FEMALE (eg. urgency, menstruation/menarche, discharge, pain or masses in ovaries/uterus ______________
MUSCLE AND SKELETON (eg. joint pain, stiffness, weakness, back pain, fractures) _____________________
NEUROLOGICAL (eg. seizures, paralysis, clumsiness, memory, vision changes, speech problems, sensation
alteration) ____________________________________________________________________________________

Integrative Health Institute
46 Sherbourne Street, 2nd Floor I Toronto ON I M5A2P7 I 416.260.6038

Source: http://www.integrativehealthinstitute.ca/wp-content/uploads/2012/08/ND.Intake.pdf

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