EpiGeneticsUSA Naturopathic Health Intake Form

EpiGeneticsUSA Naturopathic Health Intake Form

Please complete this form as accurately and thoroughly as possible. This information is confidential and will help Dr. Patrick create a personalized health plan for you.

1. Patient Identification & Contact Information
2. Consent & Privacy Agreement

By submitting this form, I acknowledge and agree to the following:

  • I understand that Dr. Patrick is a Naturopathic Doctor who uses non-invasive, holistic practices to stimulate the body's natural healing mechanisms.
  • I understand that naturopathic medicine is intended to supplement, not replace, conventional medical care.
  • I consent to the collection, storage, and processing of my health information for the purpose of providing naturopathic health coaching.
  • I understand that all information provided will be kept confidential in accordance with applicable privacy laws.
  • I agree to provide accurate and complete information to the best of my knowledge.
  • I understand that EpiGeneticsUSA will use this information to create customized recommendations and action plans.
3. Past Health Information

Please check all that apply to your immediate family (parents, siblings, grandparents):

Please list any medical conditions you have been diagnosed with:

Please list any surgeries or hospitalizations, including dates:

Please list any significant injuries, including dates:

Please check all that apply:

Please list any known allergies (medications, foods, environmental):

Have you previously consulted with:

6. Future Health Goals

What are your primary health goals? Please list in order of importance:

What motivates you to improve your health at this time?

What obstacles do you face in achieving your health goals?

What support systems do you have in place to help you achieve your health goals?

How would you rate your commitment to making lifestyle changes to improve your health?

Which areas of naturopathic care are you most interested in? (Check all that apply)

7. Lifestyle & Environmental Factors

Do you have any known food sensitivities or intolerances?

8. Additional Information
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