Today's Date
*
MM
DD
YYYY
Legal Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Age
*
Gender
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Phone
*
(###)
###
####
I agree to receive communications by text message about my inquiry. You may opt-out by replying STOP or reply HELP for more information. Message frequency varies. Message and data rates may apply. You may review our Privacy Policy to learn how your data is used.
Marital Status
*
If patient is a minor, then who is responsible for the minor?
Name of Parent(s)/Legal Guardian(s), Relationship to Minor, and Phone Number
Occupation/Employer
*
How did you hear about us?
*
Google, Family, Friend, Referral from another doctor, etc.
Type of Appointment that you are interested in:
*
Reason for Appointment
*
List your problems or any health goals starting with the most important concern. If applicable, list when it began and when you were diagnosed.
When was your last physical checkup?
MM
DD
YYYY
Current Weight (in lbs)
*
Current Height (in ft)
*
Blood Type
*
Which form of medicine do you prefer?
*
Everybody is a little different! Some people have no issues swallowing pills and prefer not to taste their medicine. However, liquid forms are best absorbed in the body. Others are open to potentially yucky or yummy botanical tinctures, liquid vitamins, powdered herbs added to water, etc.
While others are a kid-at-heart and will eat medicine in candy form all day!
Check which form you prefer to take:
General
*
Head, Eye, Ear, Nose, Throat (HEENT)
*
Cardiovascular/Respiratory
*
Endocrinology
*
Gastrointestinal
*
Genitourinary
*
Musculoskeletal
*
Pain, weakness, or numbness in:
Skin/Hair/Nails
*
Hematology/Lymphatic
*
Neurology
*
Psychiatric
*
Gynecology
Date of last menstrual period (LMP)
MM
DD
YYYY
Date of last Pap smear
MM
DD
YYYY
Was it a normal cytology (pap smear)?
Are you pregnant or breastfeeding?
Certain herbs/supplements are contraindicated for pregnancy and lactation. Safety is a priority!
Number of Pregnancies
Have you ever had any miscarriages, abortions, etc.?
What form of birth control do you use?
Taking any hormones, steroids, birth control pills, injections, IUD (intrauterine device), implants, inserts, etc.
Have you had a mammogram?
If you have PMS
If you have Menopause
Male Health
Current List of Medications and Supplements
List Reason for Medication (e.g. anxiety), Medication/Supplement Name (e.g. alprazolam), Dosage (e.g. one 0.5 mg pill), and Frequency (i.e. 3 times a day).
What other medications and/or supplements have you tried, but didn't work?
Medication/Supplement Name (e.g. lisinopril), Amount (e.g. 20 mg), and Reason for Discontinuing (e.g. coughing).
Surgeries and Hospitalization?
If you had surgeries or have any more upcoming surgeries, list the type of surgery and date. If you were hospitalized, list the reason of hospitalization, date, and for how long?
Significant Trauma or any serious Dental Work?
List any car accidents, falls, freak accidents, etc. with the date. List any significant type of dental work (i.e. implant, gum graft, or any oral surgery) with the date.
Father's Status of Health
Mother's Status of Health
Siblings' Status of Health
Please list Order of Siblinghood, Age, and Conditions they have
Grandparents' Status of Health
Please be specific of which grandparent (e.g. paternal grandfather vs. maternal grandmother)
Sleep Habits
*
What do you typically eat?
Please describe your average daily diet for Breakfast, Lunch, and Dinner.
To best determine your homeopathic remedy, what foods do you typically crave (if you can eat anything in the world - whether it's healthy or unhealthy)?
*
How much water do you drink per day?
Exercise?
*
If so, what type of exercise do you enjoy, how often, and for how long?
Drink alcohol?
*
If so, how many glasses/bottles per week on average? If you have been sober, since when?
Smoking?
*
If so, how often and for how many years? If you have quit, when? If you vape or chew tobacco, how often and for how long?
Use cannabis (marijuana)?
*
If so, how much and in what form? If you have quit, when?
Use recreational drugs?
*
If so, how often, how much, and in what form? If you have quit, when?
Do you like where you live?
Home is where the heart is! Who do you live with? Is your home a safe and sacred space? Any pets?
What has helped you the most on your journey towards healing and health?
Also list what you have tried but didn't help.
How will you know when you have reached your health goals or better yet, life goals?
Let's admit it, we're all a little weird. To best figure out your homeopathic remedy, this is the area where you can share quirks about you. For example, you like to walk around the house naked or you don't like going to parties unless you know the majority of the people there. What are your fears? What kind of dreams do you have? Do you like consolation and company, or don't? This tells me more about your personality and how you interact with the world.
As a patient of Dr. Sola Natural Medicine, I am well aware:
*
that Dr. Sola is a Naturopathic Doctor (ND), not an MD or DO. Thus, I am expected and responsible to have an MD or DO as my primary care provider (PCP) in the state of Louisiana.
*
that Dr. Sola is limited to the laws of Louisiana and thus is unable to perform physical exams to "diagnose" or "treat" diseases or medical conditions, write a prescription for pharmaceutical medications, or perform minor dermatological surgery in the state of Louisiana as it is an unlicensed state for Naturopathic Physicians.
Name
*
First Name
Last Name
Today's Date
*
MM
DD
YYYY
As a patient of Dr. Sola Natural Medicine, I am well aware:
*
that I will be responsible for all charges be made in full at the time of service.
*
of the 48-hour cancellation policy. I will be billed for missed appointments (No-Show) or appointment canceled with less than 48 hours' notice. I will be billed $100 for a missed New Patient appointment and $50 for a missed Follow-up appointment. This is because another patient in need of care could've been seen at this time.
*
that I will be charged an additional $50 for every 30 minutes past my allotted appointment time.
*
that Dr. Sola Natural Medicine will require my credit card information in order for me to reserve my appointment.
*
that Dr. Sola Natural Medicine is unable to accept any health insurance, because naturopathic and homeopathic care are not covered in the state of Louisiana.
*
that fees for laboratory work, herbs, supplements, etc. are NOT included in the office visit fees.
Name
*
First Name
Last Name
Today's Date
*
MM
DD
YYYY
