Naturopathic Medicine Initial Consultation

Naturopathic Medicine Initial Consultation — Form Fields

This healthcare template includes 14 fields. Initial consultation intake form for naturopathic medicine practitioners. Free to customize and use on ZenBuild.

• Full Name (text, required)
• Date of Birth (text, required)
• Email (email, required)
• Phone Number (text, required)
• Primary Health Concern (dropdown selection, required) — options: Digestive Health, Hormonal Imbalance, Chronic Fatigue, Autoimmune Support, Detoxification, Mental Health, Weight Management, Pain Management
• Systems Review (checkboxes, optional) — options: Cardiovascular, Respiratory, Musculoskeletal, Endocrine, Immune, Nervous, Urinary, Reproductive
• Diet Quality Self-Assessment (dropdown selection, required) — options: Excellent, Good, Fair, Poor
• Exercise Frequency (dropdown selection, required) — options: Daily, 3-5x/Week, 1-2x/Week, Rarely, Never
• Stress Level (dropdown selection, required) — options: Low, Moderate, High, Very High
• Current Supplements (text, optional)
• Current Medications (text, optional)
• Interested in Herbal Medicine (multiple choice, optional) — options: Yes, No, Maybe
• Health Goals (long text, required)
• Family Health History (long text, optional)