Integrative Medicine New Patient Health History

Integrative Medicine New Patient Health History — Form Fields

This healthcare template includes 12 fields. Comprehensive health history intake for integrative and functional medicine new patients. Free to customize and use on ZenBuild.

• Full Name (text, required)
• Date of Birth (text, required)
• Email (email, required)
• Phone Number (text, required)
• Primary Concern (dropdown selection, required) — options: Chronic Fatigue, Digestive Issues, Hormonal Imbalance, Autoimmune, Pain Management, Mental Health, Weight Management, General Optimization
• Body Systems with Concerns (checkboxes, optional) — options: Cardiovascular, Digestive, Immune, Endocrine, Musculoskeletal, Neurological, Respiratory, Skin
• Diet Quality Self-Rating (dropdown selection, required) — options: Excellent, Good, Fair, Poor
• Exercise Frequency (dropdown selection, required) — options: Daily, 3-5x/Week, 1-2x/Week, Rarely, Never
• Sleep Quality (dropdown selection, required) — options: Excellent, Good, Fair, Poor, Insomnia
• Current Medications (text, optional)
• Current Supplements (text, optional)
• Health Goals (long text, required)