New Patient Forms - General

KD Natural Healthcare

652 575 309 - www.kdnaturalhealthcare.com
New Patient Forms - General
Name*

First NameLast Name
E-mail*
Phone Number*

Country CodePhone Number
Address*

Street Address

Street Address Line 2

CityProvince

Postal CodeCountry
Age*
Date of Birth*

DayMonthYear
How did you hear about KD Natural Healthcare?*
I have seen a doctor about this problem.*

YesNoNo, but I will be seeing a doctor about this within the next 30 days.

Chief Complaint
Please describe your primary complaint.*
Please indicate the location of any pain you experience.
Please rate the average intensity of your pain:
Average pain level:
Peak pain level:
How and when did the pain start?
What makes the pain worse?
What makes the pain better?

General Constitution
In general, how is...
...your sensation of body temperature, as compared to those around you?
...your sleep?
...your digestion?
...your energy?
...your mood?
Do you sweat at night?

Lifestyle
Do you smoke? If yes, how much?
Do you drink alcohol? If yes, how much?
Please describe your nutritional habits in a normal day.
Do you exercise? Of what type, intensity and frequency?
How are your relationships?
When do you feel happy and inspired?

Terms, Conditions and Policies
Privacy Policy

Your health information is private and will be treated as such according to the Ley Orgánica de Proteccion de Datos Personales 15/1999 de13 de diciembre (España). The use of your private information is solely for the information of your practitioner and will not be shared with any third party.
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Printed Name*
Date*

DayMonthYear
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