Classic form
Naturopath intake form with an eight system review grid
A naturopathic consultation asks about eight body systems and everything already being swallowed, and doing that inventory out loud costs most of a first appointment. This nineteen field intake form takes the grid and the supplements table beforehand, so the ninety minutes go on the conversation instead.
The form itself
A static copy of the finished form, exactly as it renders. Nothing here can be filled in or submitted, so read it as a reference and build your own from the button above.
Every field, and what it collects
The complete field list, in the order respondents meet it.
- Your nameNameRequired
- Date of birthDateRequired
- Best phone numberShort textRequired
- EmailShort textRequired
- What brings you in, and how long has it been going on?Long textRequired
- What have you already tried for it?Long text
- Over the last three months, how often have you noticed symptoms in each area?Rating gridRequired
- Statements:
- Digestion: bloating, wind, discomfort after eating
- Bowels: constipation, looseness or urgency
- Energy: flat mornings or an afternoon crash
- Sleep: getting to sleep or staying asleep
- Skin: breakouts, rashes, dryness or itch
- Mood: low, irritable, anxious or wired
- Head: headaches, fogginess or poor concentration
- Immunity: colds, sinus, cold sores or thrush
- Have you been diagnosed with any of these?Multiple choiceRequired
- Options: Thyroid condition · Diabetes or insulin resistance · High blood pressure or high cholesterol · Autoimmune condition · Irritable bowel syndrome or inflammatory bowel disease · Endometriosis or polycystic ovary syndrome · Anxiety or depression · Liver or kidney condition · Cancer, current or in the last five years · Pregnant or breastfeeding · None of these
- Prescribed medications, with dosesLong text
- Supplements, herbs and protein powdersTable
- Columns: Product · Dose and how often · How long for · Why you started
- What does a normal night look like?Single choiceRequired
- Options: Asleep quickly, through the night, wake rested · Asleep quickly, but awake in the small hours · Lie awake at the start, then sleep through · Broken all night · Enough hours, never feel rested
- Stress over the last month, where 1 is settled and 5 is at capacitySingle choiceRequired
- Options: 1 · 2 · 3 · 4 · 5
- Which of these describes how you eat most weeks?Multiple choiceRequired
- Options: Three meals at roughly the same times · Skip breakfast · Eat late at night · Mostly home cooked · Mostly bought or delivered · Vegetarian or vegan · Low carbohydrate by choice · Gluten free · Dairy free · Grazing rather than meals
- Water on a normal daySingle choiceRequired
- Options: Under half a litre · About one litre · One to two litres · More than two litres
- Caffeinated drinks on a normal dayNumber
- Alcohol on a normal weekSingle choiceRequired
- Options: None · One to three drinks · Four to ten drinks · More than ten drinks
- Bowel movementsSingle choiceRequired
- Options: More than once a day · Once a day · Every second day · Less often than that
- I have read the statement aboveMultiple choiceRequired
- Options: I agree, and I will tell my practitioner if my medications change
- SignatureSignatureRequired
About you
Why you are here
Systems review
What you are already taking
Sleep, stress and food
Consent
What each block of this form collects
The identity block is four fields and nothing more, because a naturopathic clinic bills directly and has no referral chain to record. The why you are here block is two long text questions, and they are deliberately placed before any tick box so the client describes the problem in their own words rather than in the vocabulary the form has already offered them. The second of the two, what have you already tried, is the question that saves the practitioner from suggesting something that failed in March. The systems review follows, then the diagnosed conditions and medications that put the grid in context. The last block is the ordinary daily detail, sleep, stress, food pattern, water, caffeine, alcohol and bowels, which is the substrate a naturopathic plan is built on and which nobody remembers accurately when asked in the room.
How to adapt this form
A womens health practice adds a cycle block after the systems grid: cycle length, the pattern of the bleed, and the symptoms that cluster in the week before it, which turns one grid row into the centre of the consultation. A clinic doing a lot of gut work replaces the bowel radio with a stool frequency and form table over seven days and adds a food and symptom timing question, since in that work the useful signal is when the symptom arrives relative to eating. A practice that runs functional testing adds an upload for previous pathology results and a question about which tests have already been done in the last year, so the same panel is not ordered twice.
What makes this form work
Eight systems in one grid, three months of context
Digestion, bowels, energy, sleep, skin, mood, head and immunity, each rated never through daily. The eight rows are the shape of a naturopathic case history, and asking them as one grid rather than eight questions is why clients finish it.
Four columns turn a supplement list into usable information
Product, dose and how often, how long for, and why you started. A list of five names tells the practitioner nothing about whether a dose is meaningful or a trial has run long enough, and the fourth column often reveals a belief worth talking about.
The two open questions come before any tick box
What brings you in, and what have you already tried. Both sit above the grid so the client describes the problem in their own words before the form has taught them its vocabulary, which is the version a practitioner wants to read first.
Questions people ask
Why does a naturopath ask about systems that have nothing to do with the complaint?
Because the pattern across systems is the working method. Someone who came about skin and answers daily on digestion, most weeks on sleep and daily on afternoon energy has told the practitioner something the skin question never would. The grid takes two minutes and asks all eight at once rather than turning each into a separate question.
What makes the supplements table the most important field?
Interactions. Herbal medicines and high dose supplements act on the same pathways as prescribed drugs, and a client who lists four products by name has usually forgotten the dose, the duration and the reason. Four columns force all of that out, which is what makes the answer safe to act on rather than merely interesting.
Does the supplements table expand past five rows?
No. A table on this form renders exactly the rows it was built with, and five is the practical number for a first consultation. The paragraph above it and the thank you screen both ask the client to bring the actual bottles, because a label answers questions about dose and extract strength that a product name never does.
Why is the stress question a one to five scale rather than a list of stressors?
Because the number is comparable and the list is not. One to five over the last month can be asked again at review and the difference means something. What is causing the stress is a conversation for the consultation, where it can be asked properly, rather than a tick box that reduces someone to a category.
What does the consent paragraph actually commit the client to?
A consultation on stated terms: that naturopathic care sits alongside medical care rather than replacing it, that no diagnosis is made, that a prescribed medication will never be stopped on the practitioner's say so, and that any product cost is discussed first. The tick and the signature record that those four things were read, not that treatment was agreed.
Is it safe to put health answers in a web form?
It is ordinary practice, provided the practice treats them as health records. Answers are stored in the clinic account behind its login, read by the practitioner, and never shared without consent. The privacy paragraph above the grid says that plainly, and the linked privacy guidance sets out what a health service provider is expected to do with information like this.
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