Dr. Julia Esposito Naturopathic Doctor

Dr. Julia Esposito
Naturopathic Doctor

CONTACT DETAILS

Today’s date: ______

Name: ______Marital Status: ______

Date of Birth: ______Age: ______Gender: ______

Phone: Home ______

Cell: ______

Work: ______

Email Address: ______

What is the best way for us to contact you? ______

Mailing Address: ______

______

Occupation: ______# Children: ______

Emergency Contact: Name: ______

Relation: ______

Tel: ______

How did you hear about us?______

Do you have health insurance coverage for Naturopathic Medicine? Yes ______No ______

Name / address of present physician ______

HEALTH HISTORY

What are your main health concerns (in order of importance)?:

1. ______
2. ______
3. ______
4. ______

Please list any other health care practitioners you are seeing:

1. ______
2. ______
3. ______

Please comments (where applicable) on the results of the above therapies:

______

Please list any hospitalizations, surgeries, traumas (including emotional traumas) or major illnesses:

1. ______
2. ______
3. ______

CURRENT MEDICATIONS:

MEDICATION / DAILY DOSE / FOR HOW LONG / REASON
1.
2.
3.
4.
5.

CURRENT SUPPLEMENTS:

SUPPLEMENT / DAILY DOSE / FOR HOW LONG / REASON
1.
2.
3.
4.
5.

Do you take any over the counter medications (ie: Aspirin, Tums, etc.)? Please list:

______

Approximately how many times have you been treated with antibiotics? ______

Please list any allergies, sensitivities or adverse reactions (i.e. food, medications, and environment) that you currently experience or have previously experienced:______

Which of the following diagnostic tests have you had in the last 5 years?

Test / Date / Results
Colonoscopy
Endoscopy
Bone Mineral Density
Mammogram
Pap Test
Prostate Exam
Xrays
CT Scan
MRI
Ultrasound
Blood Test

FAMILY HEALTH HISTORY

Please indicate whether the following health conditions pertain to any member(s) of your family:

Condition / Relative / Age of Onset / Details
Cancer
Diabetes
Autoimmune Disease (e.g.Lupus,M.S.)
Substance Abuse
Mental Illness
Digestive Disorders
Osteoporosis
Skin problems
Lung Problems (e.g. asthma)
Heart Problems (e.g. High blood pressure)
Kidney Disease
Thyroid Disease
Weight concerns
Arthritis
Other

LIFESTYLE

How often do you consume the following:

Alcohol: ______Tobacco: ______Caffeine: ______

Do you exercise? ______If yes, how often? ______times per ______(i.e. day, week, month)

What type of exercise do you do? ______

Please rate your level of stress: Low ______Medium ______High ______

What are the main stressors in your life? ______

______

How many hours of sleep do you get each night? ______

How often do you have a bowel movement? ______

Please list some of your hobbies: ______

How happy are you? ______

How would you describe the emotional climate of your home? ______

Do you have any concerns regarding your emotional or mental health (please describe)? ______

______

Are you regularly exposed to any of the following at home or work?

Tobacco smoke ______Chemicals/toxins ______Animals ______Radiation _____ Well water _____

Are you aware of any past or present toxin exposure?Yes ______No _____

Please explain: ______

______

Please check off the following conditions if you have them now or if you have had them in the past
NOSE & SINUSES / NOW / PAST / MOUTH & THROAT / NOW / PAST / NECK / NOW / PAST
Frequent colds / Hoarseness / Lumps
Nose bleeds / Gum problems / Swollen glands
Stuffiness / Dental problems / Goiter
Hay fever / Difficulty swallowing / Pain or stiffness
Infections / Sores / Other
Other / Dryness / RESPIRATORY / NOW / PAST
GASTROINTESTIONAL / NOW / PAST / Frequent sore throat / Cough
Trouble swallowing / Loss of taste / Sputum
Heartburn / Other / Spitting up blood
Change in appetite / CARDIOVASCULAR / NOW / PAST / Wheezing
Nausea / Heart disease / Asthma
Vomiting / Angina / Bronchitis
Vomiting blood / High blood pressure / Pneumonia
Bowel movements
How often? / Murmurs / Pleurisy
Chest pains / Emphysema
Belching / Swelling ankles / Difficulty breathing
Passing gas / Palpitations, fluttering / Shortness of breath
Abdominal pain / Last ECG / Shortness of breath at night
Indigestion / Other
Diarrhea / URINARY / NOW / PAST / Shortness of breath lying down
Constipation / Pain on urination
Blood in stool / Increased frequency / Positive TB test
Hemorrhoids / Frequency at night / Last TB test
Black tarry stool / Inability to hold urine / Last chest x-ray
Jaundice / Frequent infections / Other
Liver disease / Kidney stones / BLOOD/LYMPHATIC / NOW / PAST
Gallbladder disease / Blood in urine / Anemia
Food allergy / Reduced urine flow / Easy bruising
Hernias / Other / Past transfusions
Ulcers / MUSCULOSKELETAL / NOW / PAST / Lymph node swelling
Last colonoscopy / Broken bones / Blood type
Other / Muscle cramps / Other
PERIPHERAL VASCULAR / NOW / PAST / Weakness / ENDOCRINE / NOW / PAST
Deep leg pain / Joint swelling / Heat or cold intolerance
Cold hands/feet / Backache
Varicose veins / Other / Thyroid trouble
Thrombophlebitis / NEUROLOGIC / NOW / PAST / Excessive thirst
Leg cramps / Fainting / Excessive hunger
Extremity numbness / Seizures/Convulsions / Excessive urination
Extremity coldness / Paralysis / Excessive sweating
Extremity swelling / Muscle weakness / Diabetes
Extremity ulcers / Numbness or tingling / Hypoglycemia
Other / Loss of memory / Hormone therapy
Involuntary movements / Other
Loss of balance
Speech problems
Other

Dr. Julia Esposito N.D & Dr. Chelsea Grant N.D

FEMALE REPRODUCTIVE / NOW / PAST / MALE REPRODUCTIVE / NOW / PAST / BREASTS / NOW / PAST
Age of first period / Hernia / Do you do breast self exams?
Last menstrual period / Testicular masses
# of days of period / Testicular pain / Lumps
Length of cycle / Impotence / Pain (or tenderness)
Bleeding btwn period / Premature ejaculation / Nipple discharge
Irregular cycles / Venereal disease / Last mammogram
Painful intercourse / Discharge of sores / Other
Painful periods / Sexually active
Excessive flow / Last prostate exam
PMS / Last PSA level
# of pregnancies / Other
# of live births / Check sexual preference
# of miscarriages / Heterosexual
# of abortions / Homosexual
Difficulty of conceiving / Bisexual
Sexual difficulties / EMOTIONAL / NOW / PAST
Vaginal discharge / Depression
Vaginal itching / Angry
Sexually active / Mood swings
Menopause / Bipolar
Age of onset / Anxiety
Hormone therapy / Tension
Last gynecological exam / Phobias
Insomnia
Last PAP smear / Drug abuse
Other / Psychiatric care
Check sexual preference / Psychological counseling
Heterosexual
Homosexual / Other
Bisexual
SKIN / NOW / PAST / HEAD / NOW / PAST / EYES / NOW / PAST
Rashes / Tension headaches / Impaired vision
Hives / Migraine headaches / Eye pain
Acne / Head injury / Tearing
Boils / Dizziness / Dryness
Itching / Other / Double vision
Eczema / EARS / NOW / PAST / Glaucoma
Psoriasis / Impaired hearing / Cataracts
Colour change / Earache / Blurring
Lumps / Dizziness / Light sensitivity
Night sweats / Discharge / Itching
Lumps / Infections / Discharge
Change in mole / Excessive wax / Blind spot
Other / Other / Other

INFORMED CONSENT FOR TREATMENT

PLEASE NOTE THAT THIS FORM MUST BE SIGNED PRIOR TO YOUR 1ST APPOINTMENT

Naturopathic medicine is the treatment and prevention of disease by natural means. Naturopathic doctors assess the whole person, taking into consideration physical, mental, emotional and spiritual aspects of the individual. Your ND will take a thorough case history and perform a relevant physical examination. It is very important that you inform your naturopathic doctor of any medical concerns or medications and supplements you may be taking. Please advise your ND if you are pregnant, suspect you are pregnant or if you are breastfeeding.

As a patient you will receive information about your diagnosis and/or treatment, alternative courses of action, the material effects, costs, expected benefits, risks, side effects and in each case the consequences of not having the diagnosis and/or treatment acted upon. As with any form of medical intervention there can be health risks associated with treatment by naturopathic medicine including acupuncture and intravenous therapy. Possible side effects may include, but are not necessarily limited to: aggravation of pre-existing symptoms, allergic reactions to supplements or herbs, pain, bruising or injury from acupuncture or intravenous needles, fainting or puncturing of an organ with acupuncture needles. This list of possible adverse reactions is by no means exhaustive.

As a patient of the clinic, 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 third parties unless required by law. If required, I understand that my naturopathic doctor may discuss my case with other health care providers. This medical record complies with the legal requirements for all medical records in the province of Ontario.

As a patient of the clinic, I understand that results are not guaranteed. With this knowledge, I voluntarily consent to naturopathic care. I intend this consent form to cover the entire course of treatment. I understand that I am free to withdraw my consent at any time.

Please ensure to give at least 24 hrs cancellation notice. This will allow for consideration of other patients who would also like to schedule an appointment. For appointments cancelled on the same day or missed appointments, a $25.00 fee will be charged.Consideration will be given to unforeseeable circumstances at the discretion of the naturopathic doctor.

Please note that medical advice cannot legally be given by email. Responding to emails is a priority, however it may take up to one week to receive a reply. Depending on the complexity of the email Dr. Esposito reserves the right to charge for her time at a flat rate of $25.00 per email. Alternatively, a 15 minute visit or phone consultation can be scheduled to review your questions in a timely manner at a rate of $40.00. All prescription renewals that are not done as part of an appointment will be billed $25.00 for the doctor's time.

Patient name (please print): ______

Signature of Patient or Guardian: ______Date: ______

Naturopathic Doctor: ______ND signature: ______

CONSENT FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL HEALTH INFORMATION

The privacy of your personal information is important to us. We understand the importance of protecting your personal information and we are committed to using and disclosing your information responsibly. All staff members who come in contact with your personal information are aware of its sensitive nature. They are trained in the appropriate use and protection of your information.

Our naturopathic doctors and administrative staff will collect, use and disclose information about you for the following purposes:

-To assess your health concerns and provide you with health care
-To advise you of treatment options
-To establish and maintain contact with you
-To remind you of upcoming appointments
-To communicate with you or other health care providers
-To allow us to efficiently follow-up for treatment, care and billing
-To complete claims for insurance purposes
-To comply with legal and regulatory requirements of our regulatory college, the College of Naturopaths of Ontario
-To invoice goods and services and process payments by credit card
-To assist this clinic to comply with all regulatory requirements and the law

Administrative staff will have access to your record of personal health information and may come into contact with personal health information that is sent to or from the clinic. They will collect, use and disclose your personal health information so as to protect your privacy and the confidentiality of your information.

I have reviewed the above information and authorize Dr. Julia Esposito, ND, and administrative staff to collect, use and disclose my personal health information as outlined above.

Patient Name: ______Date: ______

Patient Signature: ______Witness: ______

Do you give us consent to communicate with your other health care providers for release of medical information or to discuss your care? Yes ______No ______Initials: ______

Medical professional: ______

Cornwall Naturopathic Clinic
17373 South Branch Road- Cornwall, Ontario-K6K 1T3
Phone (613)932.4734 Fax (613)938.0949

Email