Women's Health Intake

Your health story, so I can care for the whole you. Fill in what you can; anything you're unsure of, we'll cover together. Everything you share is kept private.

About You

Full nameToday's dateDate of birthAgeEmailPhoneEmergency contactTheir phonePrimary doctor / specialistsReferred by

Your Health Story

Top three health concerns (most important first)When did each begin, and what may have triggered it?When did you last feel really well?What would a successful outcome look like — and by when?

Medical History

Current medical conditions or diagnosesPast surgeries or hospitalizationsFamily historyCurrent medications (name & dose)Current supplements (name & dose)Allergies or sensitivities

Nutrition & Lifestyle

A typical day of eating

Water (cups/day)Caffeine (cups/day)Alcohol (drinks/week)

Do you smoke or vape?

NoOccasionallyDaily

Movement & exercise — what and how often?Environmental exposures (mold, chemicals, water)

Anything Else

Anything else you'd like Natalie to know?What matters most to you in our work together?Signature (type your full name)

Confidential. Used only to support your wellness consultation; does not replace medical care from your physician.

Women's Health intake.

About You

Your Health Story

Medical History

Women's & Hormonal Health

Digestion, Sleep & Energy

Nutrition & Lifestyle

Anything Else