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Telephone (Parent's Work)
Date of Birth (mm/dd/yyyy)
Child Lives With
How did you hear about our practice?
I would like to receive our newsletter by email
Please list your health concerns in order of importance
List all vitamins/minerals/herbal supplements your child currently taking
List all prescription and non-prescription medications your child is currently taking
List any major illnesses, injuries and/or surgeries that your child has had and when
RubellaDiaper rashStomach achesMumpsCradle capHeadachesMeaslesDiarrheaEar infectionsChickenpoxConstipationHivesWhooping coughHigh feversRashesScarlet feverBedwettingEczemaPolioStrep throatRheumatic feverFrequent coldsColicSleep problemOther
Chicken PoxPolioFlu ShotHepatitisAMeasles, Mumps, RubellaDiptheria, Pertussis, TetanusChicken Pox
Did your child experience any adverse effects from vaccinations? If yes, please explain
Does your child have any medical allergies or sensitivities? Please list:
Weight 1 year ago (lbs)
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.
Was this child adopted?YesNo
If yes, at what age?
Mother's age at time of child's birth
Did the mother receive medical care during the pregnancy?YesNo
Did the mother experience any of the following during pregnancy?YesNo
BleedingNauseaPhysical/emotional traumaVomitingThyroid ProblemsHigh Blood PressureDiabetesOther
If other, please explain
UltrasoundChorionic villi samplingTriple screenAmniocentesisMaternal serum screeningOther
Please elaborate on what the mother was using
TobaccoAlcoholVitamins and/or supplementsRecreational drugsPrescription medicationsOver-the-counter meds
Type of birthVaginalC-section
Pre-term (less than 37wks)Full-term (38-42 wks)Post-term (43+ wks)
InductionChorionic villi samplingUse of forcepsMaternal serum screeningOther
If other, please list all interventions
Were there any complications during delivery (eg. breech)?
Length of labour (hrs)
Weight of infant at birth (kg/lbs)
JaundiceRashesSeizuresInfectionsBirth InjuriesBirth DefectsDifficulties with feeding
At what age did your child first:
How was your infant fed?BreastfedFormula: Cow's Milk/Soy/Other
For how long?
Did your infant experience any reactions to the breast milk or formula?
What foods were introduced before 6 months? Please list the approximate month and any reactions.
What foods were introduced between 6 and 12 months? Please list the approximate month and any.
I attest that the information provided is true and accurate to the best of my knowledge.
Signature (Full Name)
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:
There are some slight health risks to treatment by Naturopathic Medicine. These include but are not limited to:
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:
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)