Naturopathic Intake Form

Good day,

Thank you for taking a few minutes to complete this. These questions help me get a clear, grounded overview of what’s been happening in your body — so we can use our time together wisely and focus on what matters most.

Please answer as simply and honestly as you can. Short answers are completely fine.

A) Your top priorities

What are your top 3 concerns right now? (please prioritize)

When did you first notice this — and what was going on in your life around that time?(Examples: stress, travel, illness, medication changes, hormone shifts, life changes, etc.)

What would feel like a win in the next 30 days?(What do you most want to be different?)

B) Your current baseline

1. Sleep:

Typical bedtime:

Typical wake time:

Do you wake during the night? (Yes/No)

Sleep quality (0–10):

2. Energy

Overall energy (0–10):

Best time of day:

Worst time of day:

3. Digestion: (check any that apply)

Anything else you want me to know (optional):

How often are your bowel movements? (daily / not daily / varies)

4. Stress + nervous system:

Stress load (0–10):

What are your top 1–2 triggers right now?

C) Daily rhythm

1. Food rhythm:

Biggest meal tends to be:breakfastlunchdinnervaries

Anything you notice food makes better or worse?

2. Movement:

What kind of movement do you do (if any), how often, and does it help? (Yes/No/Not sure)

D) Current supports + background

Supplements + medications:Please list what you’re currently taking (include dose if you know it).

Relevant health history:Any diagnoses, surgeries, injuries, or major health events you think are important.

The most important thing you want me to understand about you and your health is:(2–3 sentences is perfect.)

Optional (but strongly helpful): Client Summary

(This section helps me synthesize quickly — keep it short and simple.)

My top 3 symptoms are:

My top 3 goals are:

The patterns I’ve noticed are:

The 3 questions I want to make sure we cover are: