Integrative Health Intake Form

Please complete the following medical information. This data allows us to understand your current health status and design a personalized plan based on integrative medicine and scientific evidence.

Patient Information

Full name *

Preferred name

Date of birth *

Age

Phone number *

Email address *

City / State / Country *

Emergency contact (Name and phone) *

Gender identity

Female Male Non-binary Prefer not to say Other

Medications and Supplements

Prescription medications

Supplements, vitamins or hormones

Lifestyle

Known allergies

Use of tobacco, alcohol, or other substances

Exercise routine

Type of diet

Recent dental procedures

Vitamin D level (if known)

Sleep quality (1 to 10)

5 / 10

Stress level (1 to 10)

5 / 10

Describe your sources of stress:

Laboratory studies / imaging / previous studies

To send your files, please:

Send files by email

Your email client will open with the studies attached. If you use Gmail from the browser, you can drag files to the email.

Note: You can send files in PDF, JPG or PNG format. Include your name in the email subject.

Female Health (if applicable)

Menstrual cycle

Number of pregnancies

Last Papanicolaou date

Uterine health evaluations

Last mammogram date

Integrative Health Intake Form

Patient Information

Main Goals and Intentions

Medical History

Medications and Supplements

Lifestyle

Female Health (if applicable)

Thank you for completing this form!

Integrative Health Intake Form

Patient Information

Main Goals and Intentions

Medical History

Medications and Supplements

Lifestyle

Female Health (if applicable)

Patient Declaration and Consent

Thank you for completing this form!