Integrative Medicine Patient Initial Appointment Form

Patient Name

Date

1. MAIN HEALTH CONCERN

What do you need help with?

Top concerns in order of importance

1

2

3

When did this problem begin?

Did anything seem to trigger it?

YesNo

Describe

What makes it better?

What makes it worse?

What have you already tried?

2. CURRENT SYMPTOMS

Other

3. HEALTH HISTORY

Past Medical History

Please list diagnoses, chronic conditions, and significant infections

Surgeries / Hospitalizations

Please list any surgeries or hospital admissions

Family History

Please specify

Who in your family has these conditions?

Social History

Marital / relationship status

Living situation

Tobacco / vape

YesNo

Amount per day

Alcohol

YesNo

Units/week

Recreational drugs

YesNo

What ones

4. LIFESTYLE FACTORS

Diet

Please specify

Additional notes

Sleep

Exercise

Type of exercise

Frequency

Any limitations?

Stress

Stress level

LowModerateHighVery high

Please specify

How do you manage stress?

Details

5. MENTAL / EMOTIONAL / SPIRITUAL HEALTH

Therapy / counseling history

Major life events in the past 1–2 years or prior to onset of symptoms

Support system

StrongModerateLimited

Are spiritual or faith practices important to you?

YesNoPrefer not to say

Would you like emotional health support included in your care?

YesNoMaybe

6. MEDICATIONS, SUPPLEMENTS & ALLERGIES

Prescription Medications

List name, dose, and reason for use

Over-the-Counter Medications

Supplements / Herbs

Allergies

None knownMedication allergiesFood allergiesEnvironmental allergies

Reaction(s)

7. HEALTH GOALS & PRIORITIES

Top 3 health goals

1

2

3

Symptoms you want to improve first

What would better health allow you to do?

What are you hoping to get out of this visit?

Ready for change

Not readySomewhat readyReadyVery ready

8. CONSENT & SIGNATURE

I confirm that the information provided is complete and accurate to the best of my knowledge. *

Patient Signature

Draw signature|Type signatureClear

Date