Dear Patient,

Thank you for your interest in naturopathic care and the opportunity to work with you.
Naturopathic medicine is an approach to care that provides an array of treatment
options. However, more importantly, I believe naturopathic medicine offers a distinctly
different way to thinking about health.
The following pages are the start of our comprehensive discussion to learn about you.
This form is somewhat long, but I appreciate your time to thoughtfully answer these
questions.
The first office visit is where we gather the largest amount of information. Accordingly,
this visit can last 1 - 1 hours. In order for me to prepare for this visit, I kindly request
that this form be mailed or faxed to Integral Naturopathic Medicine at least 2 days prior
to your first appointment. Additionally, if you have recent laboratory work or pertinent
medical records, please bring these to the visit.
Thank you again for your interest in working with me. I look forward to meeting you.
Sincerely,

C. Keith Wilkinson, NMD

Naturopathic Physician

20325 N. 51st Ave., Suite 112 Glendale, AZ 85308 P (623) 444-4482 F (623) 328-8402
www.IntegralNatMed.com

New Patient Form ADULT

Date:
Patient Information
Name:
Address:
City:

State:

Telephone # Home:

Zip Code:

Cell:

Work:

E-mail address:
Age:
Married
Live With:

DOB:
Separated
Spouse

Occupation:
Employer:

Gender:
Divorced
Partner

Widowed
Parents

Single
Children

Hours per week:

Partner
Friends
Alone

Retired/Not Working

Additional Information
Primary Care Physician:
Address:

Phone #:
City:

State:

Zip:

Emergency Contact:
Relationship to You:

Contact #:

Referral Information
How did you hear about Dr. W ilkinson?
W ere You Referred by a Physician?
Y
N
If yes, could you provide us with information for the referring physician?
Referring Physicians Name:
Address:

City:

State:

Zip:

Telephone Number:
20325 N. 51st Ave., Suite 112 Glendale, AZ 85308 P (623) 444-4482 F (623) 328-8402
www.IntegralNatMed.com

Page 1 of 8

The following questions will help me understand your expectations.

1. Why did you choose to come to Integral Naturopathic Medicine?

2. What do you know about naturopathic medicine?

3. What expectations do you have for this initial visit?

4. What long term expectations do you have regarding your health?

5. Any other expectations you have that I should know about?

6. What is your present level of commitment to address any underlying causes of your health
concerns that relate to your lifestyle? (Rate 0 - 10, 10 = 100% committed)
0
1
2
3
4
5
6
7
8
9
10
7. What lifestyle habits do you currently engage in that you believe support your health?

8. What lifestyle habits do you currently engage in that you believe harm your health?

9. What potential obstacles do you foresee in addressing the lifestyle factors which may
undermine your health and/or adhering to therapeutic protocols we might try?

10. Who do you know that will consistently support you with lifestyle changes we might try?

20325 N. 51st Ave., Suite 112 Glendale, AZ 85308 P (623) 444-4482 F (623) 328-8402
www.IntegralNatMed.com

Page 2 of 8

Total Wellness Graph

Wellness is a balance of
many factors. Using the
circle, shade your level of
satisfaction in each area as it
relates to you.

Physical
Environment
Career

Example:
Family &
Friends

For example, if you are

extremely happy in your
career, shade the entire pie
shape for career.
Do the same for each area,
starting from the center point
radiating outwards.

90%

Money

70%

60%

100%

80%

80%

Health

Personal
Growth

50%

Fun &
Recreation

Are you currently receiving medical care? Y

80%

Significant Other/
Romance

If yes, where and from whom:

If no, when and where did you last receive medical care?

What was the reason?

What are your most important health problems? List in order of importance.
1.
2.
3.
4.
5.
6.
7.
Do you have any known contagious diseases at this time? Y N
If yes, what?

20325 N. 51st Ave., Suite 112 Glendale, AZ 85308 P (623) 444-4482 F (623) 328-8402
www.IntegralNatMed.com

Page 3 of 8

Family History
Father

Mother

Siblings

Mat/Paternal Grand M/F

MGM

MGF

PGM

PGF

Spouse

Children

Age if living:
Age when died:
Reason for death:
If cancer, type:
If has condition in column on left, place an X in the appropriate box below.
High Blood Pressure:
Heart Attack/Stroke:
Heart Disease:
Asthma/Allergies:
Mental Illness:
Auto-Immune Disease:
Diabetes Mellitus:
Osteoporosis:

Childhood Illnesses
Did you have the following Disease (D), Immunized (I), or Neither (N):
Hepatitis (A / B)

D I N

Varicella (Chicken Pox)

D I N

Hemophilus (Hib)

D I N

Rotavirus

D I N

Diptheria (DTaP)

D I N

Measles (MMR)

D I N

Pneumococcal (PCV)

D I N

Tetanus (DTaP)

D I N

Mumps (MMR)

D I N

Polio (IPV)

D I N

Pertussis (DTaP)

D I N

Rubella (MMR)

D I N

Did you have any significant reaction to any immunization?

If yes, explain:

Doctor, Hospitalization, Surgery, Imaging

Please Note When & Why You Have Had Each of the Following:
X-Rays:

MRI/CT Scans:

Ultrasounds:

EKG:

TB Test:

Last Doctor Visit:

Last Dental Visit:

Last Eye Exam:

List any other major illness, trauma, medical interventions not yet mentioned:

Allergies
Are you hypersensitive or allergic to:
Any drugs?
Any foods?
Any substances in the environment or chemicals?
Have you ever had allergy testing? If yes, indicate when and details.
20325 N. 51st Ave., Suite 112 Glendale, AZ 85308 P (623) 444-4482 F (623) 328-8402
www.IntegralNatMed.com

Page 4 of 8

Current Medications / Supplements

Prescription Medications
Name
Dosage

Since

Supplements
Dosage

Since

Name

OTC Medications (i.e., Ibuprofen, antacids)

Name
Dosage
Since

Other/Additional Space
Name
Dosage

Since

General
Current Height:

/ Weight:

Maximum Weight:

Weight 1 year ago:

When:

Ideal Weight:

Do you have sufficient energy throughout day? Y N

When:

If not, when is energy best?

Worst?

Habits/Lifestyle
Main interests and hobbies?
Do you exercise?

Y N

If yes, what kind/how often?

Hours of sleep each night?

Do you have a religious/spiritual practice? Y N P

Sleep well?

Y N

Awake rested?

Y N

Enjoy your work?

If yes, what?
Y N

Do you need naps during day?

Y N

Spend time outside?

Y N

If nap, how long/often?

How many hours of TV per day?

Have a supportive relationship?

Y N

How much time/day in relaxation?

Have a history of abuse?

Y N

Do you eat 3 meals a day?

Y N

Been treated for drug dependence?

Y N P

Do you drink coffee?

Y N P

Use alcoholic beverages?

Y N P

Drink black/green tea?

Y N P

Treated for alcoholism?

Y N P

Do you drink sodas?

Y N

Do you use tobacco?

Y N P

How many years and packs/day ?

note - Y = a condition you have now

If yes, quantity per day or week.

Do you have a sweet tooth?

N = Never had

Y N P

P = Significant problem in the past

20325 N. 51st Ave., Suite 112 Glendale, AZ 85308 P (623) 444-4482 F (623) 328-8402
www.IntegralNatMed.com

Page 5 of 8

Environmental Exposure
Did you grow up in an industrial area such as chemical factories, refineries, agriculture, etc.?

YN

If yes, name the type of industry.

Do you currently live in an area where you are exposed to possible environmental pollutants?

YN

If yes, name the type of industry.

Do you work in an environment where you are exposed to solvents, fumes, paint, chemicals?

YN

If yes, provide detail.

Are you sensitive when exposed to new carpeting, new paint, gasoline, perfumes, new cars?

YN

If yes, provide detail.

Do you use pesticides, herbicides, or other chemicals around your home?

YN

If yes, provide detail.

REVIEW OF SYSTEMS
Mental / Emotional
Treated for emotional problems?
Mood Swings?
Considered/Attempted suicide?
Poor concentration?

Y
Y
Y
Y

N
N
N
N

P
P
P
P

Reactions to immunizations?
Chronic fatigue?
Chronically swollen glands?

Y N P
Y N P
Y N P

Hypothyroid?
Hypoglycemia?
Excessive thirst?
Fatigue?

Y
Y
Y
Y

N
N
N
N

Seizures?
Muscle weakness?
Loss of memory?
Vertigo or dizziness?

Y
Y
Y
Y

N
N
N
N

P
P
P
P

Rashes?
Acne, Boils?
Color Change?
Lumps?

Y
Y
Y
Y

N
N
N
N

P
P
P
P

Headaches?
Migraines?

Y N P
Y N P

Depression?
Anxiety or nervousness?
Tension?
Memory problems?

Y
Y
Y
Y

N
N
N
N

P
P
P
P

Reactions to vaccinations?
Chronic infections?
Slow wound healing?

Y N P
Y N P
Y N P

Heat or cold intolerance?

Diabetes?
Excessive hunger?
Seasonal depression?

Y
Y
Y
Y

N
N
N
N

P
P
P
P

Paralysis?
Numbness or tingling?
Easily stressed?
Loss of balance?

Y
Y
Y
Y

N
N
N
N

P
P
P
P

Eczema/Hives?
Itching?
Perpetual hair loss?
Night Sweats?

Y
Y
Y
Y

N
N
N
N

P
P
P
P

Head Injury?
Jaw/TMJ problems

Y N P
Y N P

Immune

Endocrine
P
P
P
P

Neurologic

Skin

Head

note - Y = a condition you have now

N = Never had

P = Significant problem in the past

20325 N. 51st Ave., Suite 112 Glendale, AZ 85308 P (623) 444-4482 F (623) 328-8402
www.IntegralNatMed.com

Page 6 of 8

Eyes
Spots in eyes?
Impaired vision?
Blurriness?
Color blindness?
Double vision?

Y
Y
Y
Y
Y

N
N
N
N
N

P
P
P
P
P

Impaired hearing?
Earaches?

Y N P
Y N P

Frequent colds?
Stuffiness?
Sinus problems?

Y N P
Y N P
Y N P

Frequent sore throat?

Teeth grinding?
Gum problems?
Dental cavities?

Y
Y
Y
Y

Lumps?
Goiter?

Y N P
Y N P

Cough?
Spitting up blood?
Asthma?
Pneumonia?
Emphysema?
Pain on breathing?
Shortness of breath at night?
Tuberculosis?

Y
Y
Y
Y
Y
Y
Y
Y

Heart disease?
High/Low Blood Pressure?
Blood clots?
Phlebitis?
Rheumatic Fever?
Swelling in ankles?

Y
Y
Y
Y
Y
Y

Trouble swallowing?
Change in thirst?
Change in appetite?
Nausea/vomiting
Ulcer?
Jaundice (yellow skin)?
Gall Bladder disease?
Liver Disease?
Hemorrhoids?

Y
Y
Y
Y
Y
Y
Y
Y
Y

Cataracts?
Glasses or contacts?
Eye pain/strain?
Tearing or dryness?
Glaucoma?

Y
Y
Y
Y
Y

N
N
N
N
N

P
P
P
P
P

Ringing?
Dizziness?

Y N P
Y N P

Ears

Nose and Sinuses

Nose Bleeds?
Hayfever / Post Nasal Drip?
Loss of smell?

Y N P
Y N P
Y N P

Mouth and Throat

N
N
N
N

P
P
P
P

Copious saliva?
Sore tongue/lips?
Hoarseness?
Dry Mouth?

Y
Y
Y
Y

N
N
N
N

P
P
P
P

Swollen glands?
Pain or stiffness?

Y N P
Y N P

Sputum?
Wheezing
Bronchitis?
Pleurisy?
Difficulty breathing?
Shortness of breath?
Shortness of breath lying down?

Y
Y
Y
Y
Y
Y
Y

N
N
N
N
N
N
N

P
P
P
P
P
P
P

Y
Y
Y
Y
Y

N
N
N
N
N

P
P
P
P
P

Y
Y
Y
Y
Y

N
N
N
N
N

P
P
P
P
P

Neck

Respiratory
N
N
N
N
N
N
N
N

P
P
P
P
P
P
P
P

Cardiovascular
N
N
N
N
N
N

P
P
P
P
P
P

Angina?
Murmurs?
Fainting?
Palpitations/Fluttering?
Chest pain?

Gastrointestinal

note - Y = a condition you have now

N
N
N
N
N
N
N
N
N

P
P
P
P
P
P
P
P
P

Heartburn?
Abdominal pain or cramps?
Belching or passing gas?
Constipation?
Diarrhea?
Bowel Movements: How many per day?
Black stools?
Blood in stool?

N = Never had

Y N P
Y N P

P = Significant problem in the past

20325 N. 51st Ave., Suite 112 Glendale, AZ 85308 P (623) 444-4482 F (623) 328-8402
www.IntegralNatMed.com

Page 7 of 8

Urinary
Pain on urination?
Frequency at night?
Frequent infections?

Y N P
Y N P
Y N P

Joint pain or stiffness?

Broken bones?
Muscle spasms or cramps?

Y N P
Y N P
Y N P

Increased frequency?
Inability to hold urine?
Kidney stones?

Y N P
Y N P
Y N P

Musculoskeletal
Arthritis?
Weakness?
Sciatica?

Y N P
Y N P
Y N P

Blood / Peripheral Vascular

Easy bleeding or bruising?
Deep leg pain?
Varicose veins?

Y N P
Y N P
Y N P

Anemia?
Cold hands/feet?
Thrombophlebitis?

Y N P
Y N P
Y N P

Male Reproduction
Hernias?
Testicular pain?
Venereal disease?
Are you sexually active?
Sexual orientation:
Impotence?
Premature ejaculation?
Birth control? Type?

Y
Y
Y
Y

N P
N P
N P
N

Y N P
Y N P

Testicular masses?
Prostate disease?
Discharge or sores?
Chlamydia?
Gonorrhea?
Condyloma?
Herpes?
Syphilis?

Y
Y
Y
Y
Y
Y
Y
Y

N
N
N
N
N
N
N
N

P
P
P
P
P
P
P
P

Female Reproduction / Breasts

Age of first menses?
Age of last menses? (if menopausal)
Length of cycle?
Duration of menses?
Painful menses?
Heavy or excessive flow?
PMS?
If yes, what are your symptoms?

Endometriosis?
Ovarian cysts?
Difficulty conceiving?
Cervical Dysplasia?
Sexual difficulties?
Gonorrhea?
Herpes?
Are you sexually active?
Do you do breast self exams?
Breast pain/tenderness?

days
days
Y N P
Y N P
Y N P

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

N
N
N
N
N
N
N
N
N
N

P
P
P
P
P
P
P
P
P

Date of last annual exam / PAP

Are cycles regular?
Y N
Bleeding between cycles?
Y N P
Pain during intercourse?
Y N P
Clotting?
Y N P
Discharge?
Y N P
Birth control?
Y N P
What type?
Number of pregnancies:
Number of live births:
Number of miscarriages:
Number of abortions:
Menopausal symptoms?
Y N P
Abnormal PAP?
Y N P
Chlamydia?
Y N P
Condyloma?
Y N P
Syphilis?
Y N P
Sexual orientation:
Breast lumps?
Y N P
Nipple discharge?
Y N P

Is there anything else you would like to add?

Thank you for completing this form. See you at Integral Naturopathic.
20325 N. 51st Ave., Suite 112 Glendale, AZ 85308 P (623) 444-4482 F (623) 328-8402
www.IntegralNatMed.com

Page 8 of 8