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Dr. Jon Dunn, Licensed Naturopathic Physician
Last Name
First Name:
MI
Date (mm/dd/yy)
Street Address Line 1
Address Line 2
Home Phone Number
Message Phone Number
E-Mail Address
Emergency Contact Name
Emergency Contact Phone Number
City
State
Zip Code
Known Allergies(Check all that may apply. Use space to give details and description of reaction)
Use TAB button to move to next field. Use SPACE BAR or MOUSE CLICK to check boxes.
Please limit responses to space available within borders of the boxes.
Major Surgeries/Approximate Dates
Major Illnesses/Approximate Dates
Family History (Siblings, Parents, Grandparents)
Your Profession
Medications. (including natural hormones) Please list name and purpose (i.e. atenolol - blood pressure)
Women:
Approximate date last menstrual period ended:
Number of Pregnancies
Number of Children
Coffee Intake
Type and Amount
Daily
Weekly
Alcohol Intake
Tobacco
Recreational Drugs
What Brings you Joy?
Are there any significant stresses in your life at this point in time?
Please check the dietary statements applicable to you
If yes, please specify:
Thirst: Please specify type of beverage(s) and approximate daily intake in cups (8 oz. size):
Favorite spices/condiments:
Do you generally eat (Please check all that apply):
Current average daily caloric intake, if known:
Exercise (type, duration, frequency)
Are you generally rested when you wake up in the morning?
Approximate bedtime
Approximate rising time
Is your energy throughout the day generally
Rate on a scale of 1 (minimal concern) to 4 (serious concern) each condition in each category that applies to you.
Stomach/Digestion/Intestines
Liver/Skin__________
Lungs____________
Heart/Blood Vessels_____
Head Conditions/Nerves/Muscles______________________
(Includes teeth, tongue, lips)
Hormone/Skeleton_______
Immune_______________________________________
Do you have a particular religious affiliation?
If YES, in a few words, what is it?
General Body Temperature
Are you often wearing sweaters when others are wearing T-shirts?
Are you often wearing T-shirts when others are wearing sweaters?
Weight
Is weight gain too easy for you?
Is weight gain difficult for you?
Approximate Weight
Approximate Height
Age
Birthdate (mm/dd/yy)
Nature (Briefly describe your general nature)
Are there any other health concerns you would like me to be aware of?
Current Health Care Providers
How did you hear about this clinic?
Please print out this completed form and bring it with you to your first visit with Dr. Dunn.
(high blood pressure)
700 Garden View Ct., Suite 201-C, Encinitas, California 92024 (760) 632-1665
Patient Intake Form
Naturopathic Health Care, Inc.
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