Online Adult Intake Form 2018-01-22T04:13:22+00:00

Name

Address

City

Province

Postal Code

Telephone (Home)

Telephone (Bus)

Telephone (Cell)

Email

 I would like to receive our newsletter by email

 

Sex

Date of Birth (mm/dd/yyyy)

Marital Status

Number of children

Occupation

Employed by

Emergency Contact

Phone

Relation

How did you hear about our practice?

Health Concerns

Please list your health concerns in order of importance

Vitamins and Supplements

List all vitamins/minerals/herbal supplements you are currently taking

Medications

List all prescription and non-prescription medications you are currently taking

Medical History

List any major illnesses, injuries and/or surgeries that you have had and when

Allergies

Do you have any hypersensitivity or allergy to any drugs?

Do you have any food intolerances or allergies?

Do you have any environmental sensitivities?

General

Height

Weight (lbs)

Weight 1 year ago (lbs)

Family History

Please put an "L" for living and "D" for deceased, and present age or age at time of death. Indicate if the family member suffered from any disease or conditions such as cancer, high blood pressure, heart attack, stroke or diabetes.

Example

Mother

Father

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Sister(s)

Brother(s)

Dental

Do you have any amalgam fillings? If yes, how many?

Do you have any root canals? If yes, how many?

Typical Food Intake

Breakfast

Lunch

Dinner

Snacks

To Drink

Habits

Main interests and hobbies

Do you exercise? If yes, how often?

Do you smoke? If yes, for how long and how many per day?

Do you use recreational drugs? If yes, which ones?

Rate your energy

Rate your stress

Sleep

Do you have difficulty falling asleep?

How many hours of sleep do you get on average?

Do you wake up during the night? If yes, how often?

Do you feel refreshed in the morning?

Digestive Health

How frequently do you move your bowels?

Experience any of the following?

Do you have your gallbladder?

Do you have your appendix?

Female Reproductive

Age of your first menses?

How may days of menses?

How long is your cycle?

Experience any of the following?

If you experience PMS, which symptoms?

Are you sexually active?YesNoNot Applicable

Form of contraception used

Do you get yeast infections?YesNoNot Applicable

When was your last pap test?

History of abnormal pap?YesNoNot Applicable

Are you menopausal?YesNoNot Applicable

If yes, age of last menses

Do you experience any of the following?

Male Reproductive

Please indicate if any of the following applies to you

Are you currently sexually active?YesNoNot Applicable

Current form of contraception?

Please check any of the following that apply to you as well as those you have experienced in the past.

General

Skin and Hair

Eyes Ears Nose & Throat

Cardiovascular

Respiratory

Muscle Bone & Joints

Gastrointestinal

Neurological

Infections

Urinary

Signature

I attest that the information provided is true and accurate to the best of my knowledge.

Signature (Full Name)

Date (mm/dd/yyyy)

DECLARATION AND CONSENT TO TREATMENT

Naturopathic Doctors minimize the risk of harmful side effects, by supporting the body's own capacity to heal and by using the least invasive procedures for diagnosis and treatment whenever possible. However, even the gentlest therapies have potential for complications. Some therapies must be used with caution in certain diseases such as diabetes, heart, liver or kidney disease, or in specific patient populations such as pregnant or lactating women, very young children, or patients taking multiple medications. It is very important that you inform your Naturopathic doctor immediately of:

  • Any disease process that you are suffering from
  • If you are on any medication or over the counter drugs
  • If you are pregnant, suspect you are pregnant, actively attempting to become pregnant or you are breast-feeding

There are some slight health risks to treatment by Naturopathic Medicine. These include but are not limited to:

  • Aggravation of pre-existing symptoms
  • Allergic reactions to supplements or herbs
  • Pain, bruising or injury from acupuncture or blood draws
  • Fainting or puncturing of an organ with acupuncture needles

I understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others unless so directed by myself or when law requires it. I understand that I may look at my medical record at anytime and can request a copy of it or have a report drawn up by paying the appropriate fee. I understand that information from my medical record may be analyzed for research purposes and that my identity will be protected and kept confidential.

I understand that my Naturopathic Doctor will answer any questions that I have to the best of his/her ability. I understand that the results are not guaranteed. I do not expect the Naturopathic Doctor to be able to anticipate and explain all risks and complications. I will rely on the Naturopathic Doctor to exercise judgement during the course of the procedure which they feel at that time is in my best interests, based on the facts then known.

I intend this consent form to cover the entire course of treatment for my present condition. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time.

If I am unable to make my appointment I must provide advance notification within 48 hours in which case no charge will be applied.

THIS IS TO ACKNOWLEDGE that I have been informed and I understand that:

  1. Any treatment or advice provided to me as a patient is not mutually exclusive from any treatment or advice that I may now be receiving from another licensed health care provider, or may receive in the future;
  2. I am at liberty to seek or continue medical care from a physician or surgeon or other health care provider qualified to practice in Alberta;
  3. No employee, student or anyone else under the Clinic's direction or control is suggesting or advising me to refrain from seeking or following the directions of another licensed health care provider;
  4. The treatment and therapies rendered or recommended by this Clinic may be different than those usually offered by a medical doctor or other licensed health care provider.

I DECLARE that I have received a full and complete explanation of the treatment or services that I may receive and hereby authorize and consent to treatment.

I AGREE to pay my full account at the time of each visit or treatment, including fees for services, cost of supplements and remedies, as well as other applicable fees. I understand that there is a fee for completing insurance forms, letter writing, telephone consultations greater than 10 minutes and emails that take greater than 10 minutes to answer. Notice of 48 hours is required for appointment cancellation, otherwise you will be charged an administrative fee of $35.00.

Patient's Full Name

Date of Consent (mm/dd/yyyy)

  I AGREE