New Patient Form – Denver Naturopathic Doctor Brenna Hatami, ND, RN

Greetings,

Thank you for making an appointment and making a commitment to your health. To ensure that our visit is as useful as possible, it is very helpful to have you prepare before your first appointment.

During our first office visit we will spend 60-90 minutes together discussing your current health concerns, your medical history as well as your dietary and lifestyle habits. Together we will create a recommendation plan specific to your needs. It is my goal that we will work together to help you restore your health and vitality.

These forms include a questionnaire, diet diary and consent forms. Please complete all forms. You can fill out the diet diary for any three days in a row between now and your appointment.

If you need to cancel your appointment, please call at least 24 hours in advance. Barring emergencies, there will be a charge for missed appointments not canceled in advance.

Payment is expected at the time of your visit. I accept cash, check, venmo or credit card.

I look forward to working with you.

In health

Brenna Hatami ND, RN

Your name

Your Date of Birth

Address

City

State

ZIP

Occupation

Phone

Your email

What is your primary reason for coming in?

Please list any secondary concerns

Please list any medications, hormones and/or supplements you are currently using. Include brand names and dosages.

YOUR HEALTH HISTORY
Please write a brief outline of your life history, including your birth and early childhood. List major illnesses, injuries, hospitalizations, major life events or turning points in your life. Please include any periods of heavy use of alcohol, drugs, caffeine, smoking, pharmaceutical or recreational drugs. For women, please include age of first period, birth control, any pregnancies, abortions, complications. Also include menopausal symptoms and age of menopause if relevant. Please keep it simple as we will go into more detail as needed.

FAMILY HISTORY
Indicate below diseases or disorders that run in your family. Possible examples are alcoholism, allergies, arthritis, asthma, cancer, diabetes, drug addiction, heart problems, mental illness, neurological problems, obesity, respiratory problems, skin conditions, thyroid conditions, ulcers.