Cypress Natural Medicine Intake Form

Patient Name*
First Last
Patient Date of Birth*
MM slash DD slash YYYY
Patient Blood Type*
Is the person filling out this form the patient?*
- Yes
- No
Form Filler Name*
First Last
Form filler's relationship to patient*
Reason patient cannot fill out this form themselves
Patient Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Patient Home Phone
Patient Mobile Phone
Patient Email*
Emergency Contact Name
First Last
Emergency Contact Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Emergency Contact Home Phone
Emergency Contact Mobile Phone
Emergency Contact Email

Chief Complaints
please list in order of importance to you
Complaint Onset Duration
Please list all of the medications you are taking
Include over the counter medications, herbs & vitamins.
Medication Name Dose Last Taken
Surgical History
Surgery or Procedure Date of Procedure Name of Provider Performing Procedure
Trauma History
Event Date Description
Relevant Family History

Please list your occupations.
Include the length of time you performed in that role, and describe your work responsibilities in that occupation. (Include military experience.)
Occupation Start Date Stop Date Responsibilities
Do you exercise?
- Yes
- No
Describe how long and how often you exercise on average each week.
Please describe your hobbies

Do you agree to the Cypress Natural Medicine Email Policy Agreement?*
- Yes
Review the Cypress Natural Medicine Email Policy Agreement
Do you agree to the Patient Consent for Use and Disclosure of Protected Health Information?*
- Yes
Review the Patient Consent for Use and Disclosure of Protected Health Information
Phone
This field is for validation purposes and should be left unchanged.

CYPRESS NATURAL MEDICINE INTAKE FORM

Cypress Natural Medicine Intake Form

Step 1 of 11

Past Medical History

Review of Systems

Constitutional

Eyes

ENT/Mouth

Respiratory

Cardiovascular

Gastrointestinal

Psych

Genitourinary

Musculoskeletal

Skin/Breasts

Neurologic

Endocrinologic

Heme/Lymph

Allergy/Immune

Surgery or Procedure	Date of Procedure	Name of Provider Performing Procedure

Travel destinations OUTSIDE the United States	Dates spent at this destination

Travel destinations INSIDE the United States	Dates spent at this destination

Complaint	Onset	Duration

Medication Name	Dose	Last Taken

Event	Date	Description

Food, Medication or Insect Allergies	Describe your reaction

​CYPRESS NATURAL MEDICINE INTAKE FORM

​Cypress Natural Medicine Intake Form

Step 1 of 11

Past Medical History

Review of Systems

Constitutional

Eyes

ENT/Mouth

Respiratory

Cardiovascular

Gastrointestinal

Psych

Genitourinary

Musculoskeletal

Skin/Breasts

Neurologic

Endocrinologic

Heme/Lymph

Allergy/Immune

CYPRESS NATURAL MEDICINE INTAKE FORM

Cypress Natural Medicine Intake Form