New Patient Intake Form

13531 Mayes Road • Huntersville, NC 28078
ph1 - 704.892.5002 • ph2 - 704.655.7324
cristin@wellbeingnaturalhealth.com
Full Name

First NameLast Name
Gender

FemaleMale
Family Physician
Marital Status
Occupation
Date of Birth

MonthDayYear
E-mail

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Is it okay for us to call you?

YesNo
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
Relationship

Primary Health Concerns
Condition
Past Treatment
How does this condition affect you?
What other health concerns do you have?
Stats
Height
Current weight
Past max weight
When?

MonthDayYear
Blood Pressure
Blood pressure when?

MonthDayYear
Cholesterol
Cholesterol when

MonthDayYear
Childhood Illnesses
Childhood illnesses

Rheumatic FeverDiphtheriaMeaslesChicken PoxGerman MeaslesScarlet FeverMumps
Allergies and Medications
If applicable, please list any foods, drugs, medications, or environmental factors you are hypersensitive or allergic to (please include reaction)
Please list any medications (prescribed or over-the-counter), vitamins, and supplements that you are currently taking
Please list any surgical procedures or hospitalizations you’ve had, for what reason, and when