Adult Intake Form

- Name*
  First Last
- Date of Birth*
  MM slash DD slash YYYY
- Today's Date*
  MM slash DD slash YYYY
- PEI Health Card #*
- Insurance Provider*
- Annual Naturopathic Coverage*
- Age*
- Gender*
- Weight*
- Height*
- Marital Status*
- # Children/Ages*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
- Home Phone*
- Work Phone*
- Cell Phone*
- Email*
- Occupation*
- Employer*
- Emergency Contact: Name*
- Relationship*
- Phone*
- Have you had naturopathic services?*
  - Yes
  - No
- If so, when?*
  MM slash DD slash YYYY
- Date of last medical visit*
  MM slash DD slash YYYY
- Reason for visit:*
- Family Physician*
- Specialists*
Other Health Care Providers*
How did you hear about the clinic?*
Past Injuries and Dates*
Surgeries and Dates*

Currently used medications (over the counter/prescribed) and Supplements (vitamins, herbs, protein)