Please Be Advised That We Have a SCENT-FREE Policy

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Dr. Marie Matheson, B.Sc., L.Ac., ND

Naturopathic Doctor

1419 Carling Ave. Suite 209, Ottawa, On, K1Z 7L6

Tel: 613.761.1600 Email:

**Please be advised that we have a SCENT-FREE policy.**

**Please be sure to turn off your CELL PHONE before you arrive at the clinic.**

New Patient Instructions and Appointments

KEEP THIS SHEET FOR YOUR RECORDS:

Welcome to Dr. Marie Matheson’s practice. This form is a little lengthy but its purpose is to help us get the best use of our time together.

Naturopathic medicine is the treatment and prevention of diseases by natural means. A naturopathic intake assesses the whole person, taking into consideration physical, mental/emotional and spiritual aspects of the individual. A number of different approaches are used: Diet and nutritional supplements, botanical medicine, homeopathy, biotherapeutic drainage, hydrotherapy, acupuncture, injection therapies, allergy desensitization, and lifestyle counseling.

What to bring to your Initial Visit: All lab/blood work that has been done within the last year, any supplements that you are currently taking, and a pen and notepad for taking notes. Dr. Matheson does energetic testing and requires you to remove all battery devices that are on your body. It would be easier if you removed these devices before every appointment in order to save time. These include watches, fit bit, cellphones, and car keys. Please fill out the following forms well in advance of your appointment. It is important that you fill them out with as much accuracy as possible. Do not wait until the day before, as you may need to retrieve lab work from previous doctors and other valuable information. The more thorough you are, the more I can help.

Appointment questions: Should be directed to the front desk. They will gladly reschedule or book your appointments.

Please be organized: Please arrive 10 minutes before every appointment. If you are late, understand that you may not get the full allotted time for your appointment. We understand that sometimes situations arise beyond your control i.e. snow storms, freezing rain, etc. and in those circumstances; every effort will be made to accommodate you. Please bring in all the necessary paperwork to hand in. If you require photocopying of your records or test results, there will be an additional charge of $0.25 per copy.

Poor memory: I highly recommend that you bring a family member or friend to your appointments especially if you feel that you will not be able to cognitively remember what I have said during your appointments. I cannot give written summaries of what we discussed at your appointment so if your loved one would like to know what has been said they are welcome to be present at every appointment. Please feel free to bring a pen and notepad to take notes that you can refer to after the appointment.

Cancellations:

Initial Visits: Cancellations should be made at least 7 days in advance (but earlier would be appreciated). A 7 day cancellation policy is in effect for all Initial Visits. You can either call the office, or email. This is to ensure fairness to both the physician and patients. This allows us to notify patients that may be on a waiting list. We require a $100 NON-REFUNDABLE DEPOSIT to book your Initial Visit in order to secure your spot.

Follow-up Visits: Cancellations should be made at least 24 hrs in advance (but earlier would be appreciated). A 24-hour cancellation policy is in effect for all appointments. You can either call the office, or email. To avoid a full visit charge, please notify the office 24-hours before all scheduled appointments. This is to ensure fairness to both the physician and patients. This allows us to notify patients that may be on a waiting list. We will be there for you at the time reserved for you, we hope you can be there too.

If you do forget your appointment and we are able to reach you, instead of losing your appointment time we always give you the option of doing a phone consult for the remainder of the time left. For this reason please ensure that we have your cell number so we can reach you as quickly as possible.

Appointment times: Typical follow-ups require only 30 min, however if you feel that you require more time (ie. If you have many questions) please let the front desk staff know when you’re are booking your next appointment. When going over “results” follow-ups usually require 1 hour. Follow-ups that run over the scheduled time will be charged the difference in 15 minute increments.

Telephone Consultations: If you are booking in for a telephone consultation, please contact the office 5 minutes after your scheduled time. (i.e. if your appointment is booked for 1:30 pm, call the office at 1:35 pm) For ease of payment, please provide the front desk with your credit card information. Your credit card will be automatically charged after the telephone consultation is completed. If you require another follow-up visit, please book that appointment with the front desk after the telephone consultation.

Reminder calls: Our office does not have the capacity to do reminder calls. So please use this opportunity to put any future appointments in your planner or calendar as it is ultimately your responsibility to remember your scheduled appointments.

Scent Free Policy: In order to provide a healthy place of work and care, we have a strict fragrance free policy. Please ensure that you are not wearing perfume or any strong scents (deodorant, perfume, body wash). Some patients are extremely allergic to scents, and can have immediate anaphylactic reactions, therefore this policy must be respected or your appointment can be forfeited.

Return Policy for Supplements: 30 days refund on undamaged, unopened products with original sales receipt. Returns without the original sales receipt will be issued an account credit. Final sale on any refrigerated or custom-made items. (ie: Herbal Mix, Pollenguard, LDI/LDA, Probiotics)

Email: While email is a convenient way to communicate with the office, please be aware that responding to emails does take time and expertise. Any emails can be directed through the front desk to . We try to accommodate questions regarding treatment clarification at no charge. However, my office triages emails and responses are prioritized for emergencies. Contact us if you have a reasonable quick/simple question about a supplement, diagnostic test, or a therapy reaction. Anything the doctor deems in depth will require another appointment. Any discussion of new treatment options or symptoms requires you to schedule a follow up consultation. All doctors are bound by patient confidentiality and privacy laws and unable to provide any information that requires access to your patient chart over email. If you have any questions or concerns that have not been addressed, please book in a scheduled consultation or save up your questions for your next appointment.

Dr. Marie Matheson, B.Sc., L.Ac., ND

Naturopathic Doctor

Hampton Wellness Centre: 1419 Carling Ave. Suite 209, Ottawa, On, K1Z 7L6

613.761.1600

“Supporting the body’s innate wisdom to heal itself”

In order to get you on your journey to health and wellbeing, please complete the following

questionnaire as honestly and thoroughly as possible.

Adult Health History

Name______M-¨ F-¨ Today’s Date ______

Date of birth (D/M/Y) ______/______/______Age _____

Occupation______ If retired or are too ill to work, please note your previous occupation______. When did you stop working?______

Home Address______

City______Province______Postal Code ______

Email ______Cell Phone ______

Home Phone ______Work Phone ______

Spouse/Partner’s Name______Children (Name/Age) ______

Healthcare Providers: ______

Medical Doctor(s) ______

Previous Naturopathic Doctor ______

Chiropractor______Other______

Family Medical History

Please circle if any of the following pertains to blood relatives, and if on father’s-(F) or mother’s-(M) side of the family.

Cancer Parkinson’s Asthma Arthritis

Diabetes Heart Disease/Stroke Allergies Addiction

Seizures ALS/MS/Lupus/Scleroderma Mental illness Alzheimer’s/Autism

Your Main Health Concern

Please list health concerns in order of importance and when the concerns began:

1.______

2.______

3.______

4.______

5.______

Have your symptoms changed over time?______

How do your conditions/ailments affect you? ______

What do you think is happening and why? ______

Has anything helped decrease your symptoms since you became ill? If so, what helps? ______

______

****Please use separate sheet to write down in chronological order the story of your illness and when symptoms first began****

Your Past Medical History (Please circle and indicate year)

Cancer Diabetes STD

High Blood Pressure Seizures Heart Disease

Hepatitis Rheumatic Fever Thyroid Disease

How many times a year do you get the flu?______Mononucleosis No-¨ Yes-¨ What year? ______

Vaginal Yeast infections? ______How many in your past? ______

Tonsillitis? No-¨ Yes-¨ How many times in your past? ______

Strep Throat? No-¨ Yes-¨ How many times in your past? ______

Ear infections as a child? ______How many? ______Any cause associated with it? ______

Your birth (Prolonged labor, forceps delivery) ______

Were you breastfed? No-¨ Yes-¨

Have you ever been treated for emotional problems? PTSD? No-¨ Yes-¨ Describe ______

Have you ever considered or attempted suicide? No-¨ Yes-¨ When? ______

Please list all traumatic events, physical and emotional, that you have experienced during these age spans in your life (ie: accidents, injuries, hospitalizations, job loss, divorce, deaths, etc.)

Year / Event
0-1
2-3
4-5
6-7
8-11
12-14
15-18
19-25
26-40
41-50
51-60
61-70

INSECT/CAT BITES

______# of tick bites prior to illness or in distant past.

What location on body? ______Date and year of bite? ______

Black fly/Mosquito/Flea bites/Sand flea bites that caused an abnormal reaction ______

Have you been bitten or scratched by a cat? ______Did it draw blood? ______When? ______

Did your symptoms start after a pet died? ______

LOCATION

What town/area were you bitten? Cottage, mountain biking, hiking, hunting etc ______Live in a Lyme endemic area?______

TRAVEL

Illness during or recently following travel?______

Have you ever travelled to or lived in foreign countries? ______

When did you travel? ______Where? ______

Did you become ill while there or shortly after?______How long did the symptoms last? ______Camping: did you ever drink unfiltered water from a river/pond/lake?______Have you ever had malaria?______

MOLD EXPOSURE

Had you just moved to a new home or exposed to a new building when you became ill? (work, school, gym, cottage?)______. Current home: wet basements, leaks, mold or mildew live in basements or bathrooms? Past home: wet basements, leaks, mold or mildew live in basements or bathrooms? ______

TOXINS

Any breast augmentations or implants? ______If yes, what date was it done? ______Any pain associated with it? ______

Have you worked on old home renovations, refinished old furniture?______

Heavy metals: # of silver fillings (mercury)?______. # removed without using proper mercury detoxification procedure?______. Work hobby exposure: chemicals, heavy metals, fumes:______. Do you eat organic foods? Never Sometimes Often

Do you live near major power lines? ______Are you EMF sensitive? ______

OTHER EXPOSURES:

Family members ill? ______. Blood transfusion?______.

If your child is ill, was he/she breastfed?______. Does anyone in your family have Lyme disease? ______.

SYMPTOMS RELATED TO TICK BORN INFECTIONS: please bypass this question if not applicable. Please note which symptoms you have and rate their severity with “+” next to the symptom. IF VERY SEVERE PLACE +++

Pain moves from joint to joint / Sweats/Flushing/Chills/Fever
Flu like symptoms at onset of illness / Cardiac chest pain
Flu like symptoms on and off / Cardiac palpitations
Bell’s Palsy/Facial paralysis / Shortness of breath/air hunger
Pain in heels of the feet / Weight loss at onset of illness
Headache: back of the head / Poor appetite
Fatigue/poor stamina / Pain in neck/upper back/lower back
GERD-reflux
Purple or red stretch marks/ skin rashes / Sinus drainage/pain/post nasal discharge
Gastrointestinal symptoms / Disturbed sleep
Soles of the feet hurt especially when stepping out of bed in the morning / Carpal tunnel symptoms
Pain: shin pain/ lateral thigh pain / Swelling in lower extremities
Uncontrolled episodes of rage/easily angered / Numbness/tingling/prickly burning pain
Panic attacks/mood swings / Sensations of electrical shocks
Anxiety/ ADD/ OCD/PANDA’s / Unsteadiness/light-headedness/ dizziness/wooziness/ loss of balance
Muscle twitching / Muscle pain-location?______
Headache: side of the temples / Pain in the heart area or ribs
Seizures / Headache: front of the head/ through eyes
Bladder irritability / Joint pain/ stiffness/ swelling
Persistent nausea / Labs: low platelets, anemia
Do your symptoms improve with antibiotics? / Tremor

Please circle whether YOU experience these symptoms as a current problem. Please underline if it is not a problem at the moment but can be a reoccurring problem.

General

Night sweats Weight gain Sweat easily

Weight loss Fatigue Chills

Fevers Bleed or bruise easily Unusual tastes or smells

Excessive thirst Anemia Heat or cold intolerance

Sudden energy drop/ time?______Poor appetite Poor sleep

Frequent cold/flu

Skin and Hair

Rashes Change in hair or skin texture Toe Fungus

Itching Loss of hair Bumps of back of arms

Eczema Dandruff Acne

Head/ Eyes/ Ears/ Nose/ Throat

Headaches Night blindness Sinus problems

Neck masses Color blindness Nose bleeds

Hayfever Cataracts Jaw clicks or pain

Eye pain/ strain Earaches Tooth pain

Frequent colds/flu Poor hearing Mercury fillings #_____

Blurry vision Ringing in ears Recurrent sore throat

Using glasses Facial pain Mouth sores

Snoring

Heart and Circulation

High blood pressure Fainting Cold hands or feet

Low blood pressure Chest pain Swelling of hands or feet

Irregular heartbeat Varicose veins Dizziness

Blood clots Vertigo Heart flutters

Respiration

Difficulty breathing Asthma Coughing up blood

Cough Wheezing Pneumonia

Bronchitis Production of phlegm

Digestion

Indigestion/ heartburn Abdominal pain or cramps Rectal pain

Gas or bloating Nausea Hemorrhoids

Bad breath Vomiting Blood in stool

Constipation Chronic laxative use Diarrhea

Poor appetite Change in appetite Excessive hunger

Genital-Urinary

Frequent urination Unable to hold urine Kidney stones

Urgency to urinate Decrease in flow Sores on genitals

Pain on urination Distinctive/ odd color Impotency

Waking to urinate Blood in urine

Musculoskeletal

Neck pain Knee pain Muscle pain