Integrative Medicine Patient Intake Form
Personal Information
First Name
Last Name
Date of Birth
Gender
Email
Phone
Address
Emergency Contact
Name
Phone
Relationship
Health Information
What is your main reason for your visit?
Other health concerns
Goals for Integrative Medicine
Current Medications and Supplements
Please list your current medications and supplements
Medical History
Please describe your past medical history (hospitalizations, surgeries, major illnesses, etc.)
Family Medical History
Briefly list any significant family medical history
Lifestyle Information
Describe your typical diet
Describe your physical activity routine
Average hours of sleep per night
How would you rate your stress level?
Integrative & Alternative Therapies
List any integrative/alternative therapies you are currently using or have used in the past
Allergies
List any allergies (medications, foods, environmental, etc.)
Other Comments
Please provide any additional information you think may be relevant