INTAKE FORM (CONFIDENTIAL)

Integrated Health Care

Ashley Guité B.A. D.H.M.H.S

Date: ______

Name: ______

(Surname) (Given Name)

Date of Birth: DD/MM/YYYY ______Age: ______□M □F

Weight: ______Height: _____

Address: ______

City: ______Province: ______Postal Code: ______

Home Phone: ______Work Phone: ______

Emergency Contact: ______Phone: ______

Family Physician: ______Phone: ______

Occupation: ______Number of Children if any: ______

Marital Status: □ Single □ Married □ Divorced □ Widowed

How were you referred?  Physician  Self Referral  Other

FOR FEMALE PATIENTS ONLY

Age at First Menses: ______Number of Pregnancies: ______

Every disease, drug or accident leaves its mark and remains a weak point in our system. Homeopathic treatment takes into account all of these details of the past and aims to strengthen the system. It is important to know about all the ailments you have suffered in the past as well as the treatments you have taken.

What problem brings you to this appointment ______

______

______

When did the symptoms begin? ______

Are your symptoms getting worse?  Yes  No.

In the list below ALL the major illnesses so far suffered (past & present):

□ Allergy □ Ear Infections □ Luekemia □ Ringworms

□ Anemia □ Eczema □ Lumbar Puncture □ Scabies

□ Appendicitis □ Food poisoning □ Major Bleeding □ Septic Tonsils

□ Asthma □ Fungus □ Malaria □ Sexual Abuse

□ Backache □ Gallbladder □ Malnutrition □ Sinusitis

□ Boils □ German Measles □ Measles □ Small Pox

□ Bronchitis □ Goiter □ Meningitis □ Spleen

□ Cancer □ Gonorrhea □ Mononucleosis □ Strep Throat

□ Carbuncles □ Hay Fever □ Mumps □ Stroke

□ Chicken Pox □ Headaches □ Numbness □ Syphilis

□ Cholera □ Head Injury □ Paralysis □ TB

□ Cold Sores □ Hepatitis □ Pimples □ Typhoid

□ Convulsions □ Herpes □ Pneumonia □ Ulcers

□ Cramps □ HIV/Aids □ Polio □ Unconsciousness

□ Diabetes □ Hypertension □ Prolapsed Uterus □ Urticaria

□ Diarrhea □ Jaundice □ Prostate □ Venereal Warts

□ Diphtheria □ Kidney/Urine □ Psoriasis □ Whooping Cough

□ Dysentery □ Liver Disease □ Rheumatism □ Worms

□ Other: ______

______

Any Serious:

□ Depression □ Grief □ Mental Upset □ Shock

□ Disappointments □ Fright □ Nervous Breakdown

Please list any necessary information about the illnesses checked: Onset (can you trace the origin of your illness to any particular circumstance, accident, illness, or mental upset), medications used, duration, if you completely recovered, etc:

______

______

______

______

______

______

______

______

______

Are you currently taking ANY medications or supplements?

Medication/Supplement / For What? / (mg) Dosage / Frequency – Amount/Day

Please which of the following substances you are currently using:

□ Alcohol How Much? ______□ Coffee How Much? ______

□ Chewing Tobacco How Much? ______□ Recreational Drugs How Much? ______

□ Cigarettes How Much? ______□ Teas How Much? ______

Please list any major injuries you may have had in the past: ______

______

______

Please list any major surgeries you may have had in the past: ______

______

______

What vaccinations have you had? ______

______

Did you have any adverse reactions to them? Please list information below:

______

______

______

Birth History:

Did you or your mother have any problems during pregnancy? ______

Did she use any medication/drugs during pregnancy? If so what were they?

______

Were there any difficulties with your birth? ______

______

At what age did you start:

Teething / Walking
Sitting / Speaking
Standing / Urination Control/Bed Wetting

Were there any other problems about your growth and development?

______

______

______

______

Please check any of the following that may be present in your FAMILY HISTORY:

□ Alcoholism □ Diabetes □ Hypertension □ Tuberculosis

□ Alzheimer’s □ Gonorrhea □ Mental Problems

□ Cancer □ Heart Disease □ Skin Disease

□ Depression □ Hepatitis □ Syphilis

□ Other: ______

Relationship / Age / If deceased age at death / Cause of Death / Diseases
Father
Mother
Paternal
Grandfather
Paternal
Grandmother
Maternal
Grandfather
Maternal
Grandmother
Sister(s)
Brother(s)

Family History

Who in your family has had?

Asthma ______

Eczema ______

Seasonal or Year Round Allergies ______

Other Allergies (drugs/bees/food etc) ______

Sinus Problems ______

Have you been treated by a Homeopath or BIE Practitioner before? ______

Do you have any of the following symptoms? Please check all that apply.

q  Cough / q  Runny Nose / q  Nasal Polyps / q  Eczema
q  Wheezing / q  Nasal Congestion / q  Poor Sense of Smell / q  Hives/Swelling
q  Shortness of Breath / q  Itchy Nose / q  Ear Infections / q  Headaches
q  Chest tightness / q  Itchy / Watery Eyes / q  Sinus Infections / q  Snoring
q  Sneezing / q  Postnasal Drip / q  Blocked Ears / q  Fatigue
q  Phlegm / Sputum: / Color______/ q  Other

Which of the following trigger (or cause) the symptoms. Please check all that apply.

q  Grass / q  Dogs / q  Perfumes / q  Pollution
q  Hay / q  Horses / q  Insecticides / q  Exercise
q  Mold & Mildew / q  Other animals / q  Odors / q  Nervousness
q  Basements / q  Alcoholic Beverages / q  Drafts / q  Cold Air
q  Leaves / q  Cosmetics / q  House dust / q  Humidity
q  Cats / q  Aerosol sprays / q  Smoke / q  Weather Changes
q  Latex (rubber) / q  Other: ______

When are your symptoms worse?

q  Year Round
q  January / q  February / q  March / q  April
q  May / q  June / q  July / q  August
q  September / q  October / q  November / q  December

Are symptoms better away from home?  Yes  No. If yes, when? ______

Environmental Survey

How long have you lived in your house/apartment? ______

Approximately how old is your house/apartment/condo? ______

Do you live in a: / q  House / q  Apt / Duplex / q  Condo / Town House
Do you live / q  In the city / q  In the suburbs / q  Rural areas
Do you have a basement? / q  Yes / q  No
Type of heating system? / q  Hot Air / q  Steam (radiator) / q  Electric / q  Hot water baseboard
Do you use a: / q  Humidifier / q  Wood/Coal Stove / q  Dehumidifier / q  Air Cleaner
# Of Pets? Indoor or Outdoor? / q  None / q  Cats / q  Dogs / q  Birds / q  Other
Are there any tobacco smokers in your house? / q  Yes / q  No
Is your bedroom in the basement? / q  Yes / q  No
Do you have allergy proof encasing for pillow or mattress / q  Yes / q  No

What type of pillow do you have? ______

What type of comforter do you have? ______

What type of floor covering do you have? ______

Flooring you have in your bedroom / q  Wall to wall / q  Area rug / q  Animal skin / q  Bare floor

How old is your mattress? ______

What is in your mattress? (I.e. cotton, horsehair, etc.) ______

Do you have air conditioning? / q  Yes / q  No / If yes, / q  Window Unit / q  Central Air
Do you have problems with roaches or mice? / q  Yes / q  No
Do you have water leaks, mold contamination? / q  Yes / q  No
Is your home/apartment excessively humid? / q  Yes / q  No

Please list any hospitalizations regardless of cause: ______

______

______

List any food allergies and reactions experienced: ______

______

List any drug allergies and reactions experienced (i.e. penicillin, aspirin, sulfa, latex, etc): ______

______

Describe any reaction to insect stings: ______

______

List all medications & dosages (including nasal sprays, non-allergy medications, alternative/herbal products):

______

______

______

Food Stressors Section:

Check any symptoms that you have experienced:

q  Abdominal cramping

q  Anaphylactic shock

q  Arthritic type symptoms

q  Canker sores

q  Celiac’s disease

q  Constipation

q  Diarrhea or loose stools

q  Difficulty concentrating

q  Eczema

q  Fatigue or sudden drops of energy after meals

q  Gas or bloating

q  Heartburn or indigestion

q  Hives

q  Irritable bowel syndrome (IBS)

q  Irritability

q  Itching – skin or rectal

q  Migraine headaches

q  Nausea

q  Red rash around mouth, reddening or swelling of skin

q  Rhinitis

q  Runny nose

q  Stiffness of joints

q  Stomach ache

q  Swelling of lips and face

q  Swelling of the joints

q  Vomiting

q  Wheezing

Miscellaneous: Indicate any additional information about your symptoms:

______

CLINIC SECTION

Patient Name: ______Clinic #: ______

Date: ______Questionaire Reviewed: ______