Adult Intake Form (ages 13+)Dr. Jennifer Baer, ND

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* mandatory field

Please fill out this form as completely as possible.

Be sure to print and fill out a diet diary from my website and bring it with you to your first visit.


Patient Information


format: MM/DD/YYYY




Contact Information





format: X1X 1X1


Family Structure



Healthcare Provider Information


find it at: http://www.cpso.on.ca







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Context of Care








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Medical History

Describe your main health concerns in order of importance to you.  Click "add an item" (at the bottom right) for each new concern.







Trauma / Surgery

Please list any major trauma (mental, emotional or physical), injury, illness, accident or surgery that you have sustained.  Click "add an item" (at the bottom right) to list each additional event. 





Medications, Supplements and Drugs

Please list all current medications and supplements you take including prescription drugs, over the counter drugs, herbs, vitamins, minerals, homeopathics, etc.  Click "add an item" at the bottom right for each new item.








Other Substances Used
Check the box if applicable & provide details.











Allergies, Sensitivities and Exposures


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Family History

Please indicate if any of your immediate biological family members suffer from, or have suffered from, any of the following conditions by checking all applicable boxes:

























BMI, Diet and Digestion
















Lifestyle Factors
Sleep




Stress +Energy Levels






Additional Lifestyle Factors







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Reproductive + Sexual Health

Male







Female

















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