Tulsa Naturopathic Group - Forms/Registration

Tulsa Naturopathic Group - "Physicians Who Listen"


New Patient Registration--fill out if you are scheduled for an initial visit
Full Name and Gender
Date of Birth
Mailing Address/Residence
e-mail address
Phone number(s)
How did you hear about Tulsa Naturopathic Group?
Health Issue(s)
Give a brief history of current health issue(s)--when it started, what has been done so far, are you improving/getting worse, etc.
Past Medical History--chronic illnesses/diseases/accidents/injuries
For Women Only--Childbirth history, regular menstrual cycle?, menopausal?, etc
Family Medical History--heart disease, cancer, diabetes, autoimmune disease in immediate family(mom/dad/kids/granparents)
Social History--Do you smoke or drink? Any STD's? Do you exercise?
Occupational/Work History
Medication list
Allergies(to drugs or anything else) that you know about?
Supplement List(homeopathics, herbal remedies, vitamin and mineral support, etc)--include brand and dosage if possible
Do you have any specific health goals?
Any other information you want to provide?

Payment for Naturopathic Services is expected at the time of visit by cash or check only. For Phone Consultations, payment will be arranged on an individual basis.