Naturopath intake form – AI conceived model

December 28, 2023
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NATUROPATHIC INTAKE FORM PERSONAL INFORMATION:

Full Name:
Date of Birth:
(DD/MM/YYYY)
Gender:

Address:
Contact Number:
Email Address:

Occupation:
Emergency Contact:
(Name and Relationship)

intakeform chatgpt

HEALTH INFORMATION:

  • Primary Reason for Visit:
       • Describe your main concerns or symptoms.
  • History of Present Illness:
       • When did your symptoms start?
    •  • How have they progressed over time?
  • Medical History:
       • List any chronic or significant past illnesses, surgeries, or hospitalizations.
  • Current Medications and Supplements:
       • Include dosage and frequency.
  • Allergies:
       • Include both drug and non-drug allergies.

DETAILED SYMPTOM DESCRIPTION:

  • For each symptom mentioned in the “Primary Reason for Visit” and “History of Present Illness” sections, ask for:
       • The exact location of the symptom.
    •  • The character of pain or discomfort (sharp, dull, throbbing, etc.).
    •  • Any factors that worsen or improve the symptoms (time of day, weather, emotional state, etc.).
    •  • Associated symptoms (for example, nausea accompanying headaches).

EXPANDED LIFESTYLE INFORMATION:

  • Dietary Habits:
       • Describe your typical daily meals (breakfast, lunch, dinner, and snacks).
    •  • Do you have any dietary restrictions or preferences (vegetarian, vegan, gluten-free, etc.)?
    •  • Do you experience any digestive issues (bloating, indigestion, constipation, etc.)?
  • Exercise and Physical Activity:
       • Detail the type (aerobic, strength training, yoga, etc.), duration, and frequency of your exercise routine.
    •  • Do you experience any discomfort or pain during physical activity?
  • Sleep Patterns:
       • Detail your bedtime routine and sleep environment (quiet, dark, etc.).
    •  • Do you use any sleep aids or medications?
    •  • Do you experience any recurring dreams or nightmares?
  • Use of Conventional and Alternative Therapies:
       • Briefly describe your history and attitudes toward various types of health care, including conventional medicine, chiropractic, acupuncture, etc.

FAMILY MEDICAL HISTORY:

  • List any significant illnesses in your immediate family:
       • Include parents, siblings, and children.

ADDITIONAL INFORMATION:

  • Menstrual History (if applicable):
       • Age at menarche, regularity, duration, and any menstrual complaints.
  • Mental and Emotional Well-Being:
       • Describe any issues related to stress, anxiety, depression, etc.

CONSENT AND ACKNOWLEDGEMENT:

  • I hereby provide consent to the naturopath to use the information provided for my treatment.
  • I understand the nature of naturopathic treatment.

Signature:
Date:

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