Naturopath New Patient Intake Form

Naturopath New Patient Intake Form — Form Fields

This healthcare template includes 10 fields. Collect comprehensive lifestyle, diet, and health history information for new naturopathic medicine patients. Free to customize and use on ZenBuild.

• Full Name (text, required)
• Email Address (email, required)
• Date of Birth (text, required)
• Phone Number (text, required)
• Primary health concern and goals for this visit (long text, required)
• Current Health Concerns (checkboxes, optional) — options: Fatigue, Digestive issues, Hormonal imbalance, Sleep problems, Anxiety or stress, Weight concerns, Skin issues, Chronic pain, Other
• Diet Type (dropdown selection, optional) — options: Omnivore, Vegetarian, Vegan, Gluten-free, Paleo/Keto, Other
• Do you currently take any supplements or herbal remedies? (multiple choice, required) — options: Yes, No
• List current supplements or remedies (long text, optional)
• How would you rate your overall stress level? (1=low, 5=very high) (rating, required)