NATURAL PATH MEDICAL CENTER
You can't change your life until you change your mind.

Your Subtitle text
NP Form

Contact Information
First Name:
Last Name:
Address Street 1:
Address Street 2:
City:
Zip Code: (5 digits)
State:
Best Phone:
2nd Phone:
Email:

General Information
Who may we thank for referring you?:
Marital Status:
List all known Allergies (food, drugs, environment):
List Health Concerns in order of Importance:


Current Medications and Supplements:
List all Major Hospitalizations, Surgeries, and Injuries:
Current Stress Level (1 is lowest stress):
Current Energy Level (1 is lowest energy):
Ailments

Check any of the following general symptoms that you experience EVERY DAY.
Vomiting
Nausea
Itching/Rash
Discharge
Bleeding
Chronic Pain
Low Grade Fever
Urinary Incontinence
Fecal Incontinence
Constipation
Disinterest in Sex
Disinterest in Eating
Depression
Debilitating Fatigue
Dizziness
Headaches
Panic Attacks
Shortness of Breath
Diarrhea
Insomnia
Medical History
Arthritis
 Allergies/hay fever
 Asthma
Alcoholism
 Alzheimer's Disease
 Autoimmune Disease
Blood Pressure Problems
 Bronchitis
 Cancer
Chronic Fatigue Syndrome
 Carpal Tunnel
 Elevated Cholesterol
Circulatory Problems
 Colitis
 Dental Problems
Depression
 Diabetes
 Diverticular Disease
Drug Addiction
 Easting Disorder
 Epilepsy
Emphysema
 Environmental Sensitivities
 Fibromyalgia
Food Intolerance
 Gastroesophageal Reflux
 Genetic Disorder
Glaucoma
 Gout
 Heart Disease
Chronic Infection
 Inflammatory Bowel Disease
 Irritable Bowel Syndrome
Kidney or Bladder Disease
 Learning Disability
 Liver or Gallbladder Disease
Mental Illness
 Migraine Headaches
 Neurological Problems
Sinus Problems
 Stroke
 Thyroid Trouble
Obesity
 Osteoporosis
 Pneumonia
Skin Problems
 Tuberculosis
 Ulcer
Urinary Tract Infection
 Varicose Veins
 Other:






Office in Scottsdale, AZ
480.603.9273



Content copyright . Natural Path Medical Center. All rights reserved.





















































Web Hosting Companies