New Adult Consultation

Confidential · All information is held in strict confidence

1 Basic Information

Full Name

Date of Birth

Age

Gender

Today's Date

Height

Weight

Home Address

City / State / Zip

Preferred Telephone

Email Address

Occupation

Marital Status

Emergency Contact (Name, Relationship, Address, Telephone)

2 Reason for Visit

What is the reason for today's visit?

When did these complaints first arise?

What were the circumstances when the symptoms began?

What happened before the symptoms started?

3 Illness & Vaccination History

Check all childhood and past illnesses that apply

Other illnesses / date of illness (describe)

Vaccination details — dates, number of doses, and any not listed above

Have you ever had a reaction to a vaccination? If yes, describe

Childhood illnesses and injuries — chronological order

Age	Illness / Injury	Reaction & Notes

4 Medical & Sensitive Health History

If you have a history of any of the following, please complete the fields. This information is strictly confidential.

Condition	Diagnosis Date	Treatment / Notes
Chlamydia
Syphilis
Gonorrhea
HPV
Herpes
HIV
AIDS

5 Current Medications, Vitamins & Supplements

Drug / Supplement / Herb	Dosage	Indication / Reason

6 Past Medications & Extended Use

Drug / Supplement	Dosage	Indication / Period of Use

8 Timeline of Major & Traumatic Events

Please provide a brief summary of any major life-altering or traumatic events. Begin with the most recent event and work backward to one year before your birth. We will explore these in greater depth during the consultation.

Date / Age / Period	Event Description

9 Consent, Authorization & Signature

By signing below, I certify and agree that:

Printed Name

Date

Signature

Type your name above to generate your signature

Thank you for taking the time to complete this form. Your responses help us provide the most individualized and effective care for you.

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