Name______
Gender: Male / Female / Other ______
Date of birth______Current age_____
Height_____ Weight____
Home street address______
City______Province______Postal code______
Home phone______Is it okay to leave message? Yes/No
Work phone______Is it okay to leave message? Yes/No
Mobile phone______Is it okay to leave message? Yes/No
E-mail______
Do you prefer appointment reminders by email _____ or phone _____?
Would you like to receive electronic newsletters? Yes/No
Referred by ______
OR
How did you hear about clinic ______
Family Doctor ______
Emergency contact name and telephone number ______
THE FOLLOWING INFORMATION IS CONFIDENTIAL AND WILL
ONLY BE RELEASED IF YOU AUTHORIZE US TO DO SO
MUTUAL UNDERSTANDING AND CONSENT TO TREATMENT
The following information is provided to enable our sharing of a common understanding of our rights and roles in this professional therapeutic relationship. Please read this agreement and sign at the end indicating that you have understood and agreed to the following.
§ Information revealed during counseling and discussion sessions is confidential. Exceptions to this confidentiality include disclosure by you regarding intention to harm yourself or others. Your record and the information within will not be disclosed to others unless you direct us to do so or unless the law authorizes or compels us to do so.
§ Each procedure and or treatment carries with it both benefits and risks. There may be additional or alternative treatments available. You are encouraged to ask questions if you would like additional information. Although your plan will be thoroughly researched and will be customized to your unique health status and your personal goals, no guarantees are expressed or implied regarding the outcomes of treatments or procedures.
§ Full payment with cash, cheque, visa or debit is due at the time of your visit. You are responsible for payment regardless of insurance coverage.
§ Cancellation Policy: Please note that we require a minimum of 24hrs notice to cancel or change an appointment. At the Practitioners discretion, a flat fee of $40.00 will be charged for missed appointments or appointments cancelled with less than 24 hours notice (exceptions will of course be made in unavoidable circumstances). This policy ensures Stouffville Natural Health Clinic runs smoothly and that patients booking appointments can receive treatment as soon as possible.
§ Your naturopathic doctor is not available on a 24-hour basis. If you have a serious health problem that requires immediate attention, call your other doctor(s), call 911 or have someone take you to the emergency room. If you notice adverse effect from one of the components of your health plan, discontinue it, call your doctor to inform her what has occurred.
§ Please let your naturopathic doctor know if you are being treated by other health care providers. It is your responsibility to disclose changes in your condition, symptoms, contact information or treatments between visits.
§ Physical examination, naturopathic manipulations, and massage may result in injury and does involve physical contact, which may be uncomfortable for some persons. If you are uncomfortable with physical contact please let your naturopathic doctor know so she can help you find an alternative that is more comfortable to you.
§ You are encouraged to ask questions on any health-related topic and to take an active role in your health care. Natural treatments may involve encouraging you to make changes to your diet and lifestyle that can help you attain your highest level of health.
The contact information, health history, and other information that I provided on my intake form are complete and accurate. I understand and agree to the information on this page. My questions, if any, were answered to my satisfaction.
______
SIGNATURE of patient or guardian Date
Health Concerns:
What are your chief health concerns? (in order of importance to you)
______
General state of Health: □ poor □ fair □ good □ very good □ excellent
Comments: ______
List any known allergies (including food, drugs, herbs, environment, etc.):
______
Are you currently working with a medical doctor? □ Yes □ No
State of diagnosis given by MD (if applicable): ______
List any medical treatments you are undergoing and/or medications you are currently taking, including dosage and duration of use:
______
Please indicate if you have or are currently working with other practitioners (e.g. chiropractors, physiotherapists, massage therapist, psychologist etc.). If in the past, please state when and duration of treatment.
______
Screening tests (include year of test and results):
______
Immunizations (include date and it you experienced any adverse effects from them)
______
Sleep patterns (include usual time of sleep and wake, daytime naps, and any difficulties in falling or staying asleep)
______
What do you feel is your weakest organ system and why?
______
Do you exercise? □ Yes □ No
If yes, include type, frequency and duration
______
What is your Weight? ______Max. Weight: ____ Min. Weight: _____
Have you lost weight lately? □ Yes □ No If yes, how many pounds _____
List daily intake of supplements (vitamins, minerals, herbs, etc.)
______
Typical diet:
Breakfast: ______
Snack: ______
Lunch: ______
Snack: ______
Dinner: ______
List all dietary restrictions: ______
Indicate which of the following you have or may have had in the past.
37 Sandiford Dr. Suite 209, Stouffville ON L4A 7X5 (905) 642-8555
□ abscess
□ abortion
□ alcoholism
□ anemia
□ anxiety
□ arthritis
□ asthma
□ bronchitis
□ cancer
□ cold sores
□ constipation
□ depression
□ diabetes
□ diarrhea
□ eczema
□ emphysema
□ epilepsy
□ fibrocystic breast
disease
□ frequent colds
□ gallstones
□ genital herpes
□ genital warts
□ gonorrhea
□ gout
□ hay fever
□ headaches
□ heart disease
□ high blood pressure
□ HIV
□ hypoglycemia
□ Influenza
□ kidney disease
□ leukemia
□ low blood pressure
□ malaria
□ menstrual cramps
□ miscarriage
□ mono
□ MS
□ mumps
□ parasites
□ PCOS
□ peritonitis
□ pelvic inflammatory
Disease
□ pleurisy
□ pneumonia
□ PMS
□ prostatitis
□ psoriasis
□ rheumatic fever
□ rubella
□ scarlet fever
□ skin diseases
□ sinusitis
□ stroke
□ strept throat
□ substance abuse
□ syphilis
□ tonsillitis
□ tuberculosis
□ warts
□ whooping cough
□ worms
37 Sandiford Dr. Suite 209, Stouffville ON L4A 7X5 (905) 642-8555
Indicate whether you have been or are exposed/use the following (and if so, how much)
Tobacco smoke ______
Coffee ______
Tea ______
Pop ______
Alcohol ______
Recreational Drugs ______
Chemicals ______
Indicate below any health conditions that have afflicted members of your family:
Relative / Age if alive / Age at Death / Health ConditionsMother
Father
Brothers
Sisters
Children
Maternal
Grandmother
Maternal
Grandfather
Paternal
Grandmother
Paternal
Grandfather
CONTEXT OF CARE
1. Why did you choose to come to this clinic?
What do you know about our approach?
2. What three expectations do you have from this visit to our clinic?
1.
2.
3.
What long-term expectations do you have from working with our clinic?
What expectations do you have of me personally as your physician?
3. What is your present level of commitment to address any underlying causes of your signs and symptoms that relate to your lifestyle? (Rate from 0 to 10, 10 being 100% committed)
1 2 3 4 5 6 7 8 9 10
4. a) What behaviors or lifestyle habits do you currently engage in regularly that you believe support your health? (please list)
b) What behaviors or lifestyle habits do you currently engage in regularly that you believe are self-destructive lifestyle habits: (please list)
5. What potential obstacles do you foresee in addressing the lifestyle factors which are undermining your health and in adhering to the therapeutic protocols which we will be sharing with you?
6. Who do you know that will sincerely support you consistently with the beneficial lifestyle changes you will be making?
7. What do you LOVE to do?
37 Sandiford Dr. Suite 209, Stouffville ON L4A 7X5 (905) 642-8555