Patient Forms

We look forward to welcoming you to Duke Integrative Medicine.

Once you have confirmed your appointment date, please complete the appropriate intake forms, as directed by our staff.

PLEASE SUBMIT YOUR COMPLETED FORMS TO A CONFIDENTIAL MEDICAL RECORDS Fax: 919-681-0380.  If you do not have access to a Fax machine, please be sure to bring your completed forms with you to your scheduled appointment.

Physician Appointment (for patients 18 and older)

• Patient Demographics
  

• Personal Health History and Self Reflective Inventory
  

• Client Agreement and Waiver
  

• Release of Medical Records
  

Physician Appointment (for patients 5 to 17 years of age)

• Pediatric Health History
  

• Pediatric Consent for Treatment
  

Acupuncture Appointment

• Acupuncture Intake
  

• Physician Clearance
  

• Client Agreement and Waiver
  

Nutrition Appointment

• Patient Demographics
  

• Client Agreement and Waiver
  

Massage Appointment

• Patient Demographics
  

• Massage Intake
  

• Client Agreement and Waiver
  

Health Psychology Appointment

• Patient Demographics
  

• Health Psychology Intake
  

• Client Agreement and Waiver
  

Yoga Therapy Appointment

• Patient Demographics
  

• Yoga Intake Form
  

• Client Agreement and Waiver