New Life Allergy Treatment Centre Your Natural Solution to Health New Patient Health History
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1 New Life Allergy Treatment Centre Your Natural Solution to Health New Patient Health History Name PH#(home) Cell Address City Province Postal Code Date of Birth D/M/YY Age Gender address Do you exercise? How frequently? Hobbies Do you smoke? If so how much? Do you drink alcohol? If so how much? How would you rate your diet? Excellent Fair Poor It varies How would you rate your current level of stress on a scale of 0-10? MEDICAL HISTORY Do you have: Diabetes Arthritis Heart Disease Use a Pacemaker Lung disease Mental Illness Asthma Cancer Other (Please specify) Are you currently pregnant? Yes No Have you ever had anaphylactic reaction? Yes No If so, when was your last Reaction? Do you carry an epi-pen? Have you ever used it? Have you ever been tested for allergies before? Yes No How long ago? Are you currently being treated for allergies (shots, medication)? Do you currently take any prescriptions, over the counter or recreational drugs? Please list Are you currently taking Prednisone? Other steroid medication?
2 List any vitamins or natural supplements you are currently taking Have you stayed overnight in the hospital in the last three years? If so, why? What are your current health concerns (what brings you here today)? How did you hear about NEW LIFE ALLERGY TREATMENT CENTRE? If you were referred by someone, please give the name FEES: Initial assessment and allergy testing $95.00 Allergy treatment.$50.00 * All fees include tax Patients are responsible for all fees on the day of the treatment. Forms to submit to third party insurance companies are available to you on request. CANCELLATION POLICY: All rescheduled or canceled appointments require 24 hours notice. You will be charged for missed appointments if 24 hours notice is not given. I have filled out the above information to the best of my ability and believe it to be accurate. I except the terms and policies outlined above and understand my responsibilities. Patient Signature (must be 18 to sign) Date Name of parent or guardian (please print) Relationship to minor
3 PATIENT CONSENT I (my ward) understand that New Life Allergy Treatment Centre does not claim to cure any illness or disease with their techniques. I understand that the procedures used at New Life Allergy Treatment Centre do not disclose disease. Rather, gives the practitioner an indication as to the substance(s) to which the patient may have energetic incompatibilities. I understand that the most effective way to avoid symptoms caused by allergies is to avoid the allergen. Exposure to allergens has been known to cause symptoms including: asthma, cough, congestion, diarrhea, eczema, general itching, hay fever, headaches, hives, itchy watery eyes, and sinusitis, post nasal drip, shortness of breath and many others, including death. The services offered by New Life Allergy Treatment Centre are designed to test sensitivity to known allergens to assist me to determine which allergens to avoid. I understand that that there is no guarantee that all allergens to which I (my ward) may be sensitive to will be identified. New Life Allergy Treatment Centre employs various procedures that have been known to reduce sensitivity to some allergens in some cases when combined with regular professional medical care. However I understand that there is no guarantee that the procedures in my (my wards) case will be effective. Therefore I understand that I (my ward) must do my best to avoid the allergen. I (my ward) will seek medical advice and follow my (my wards) doctors instructions at all times. I understand that I (my ward) am advised to continue all medications and other treatment modalities as they have been prescribed by my Doctor unless otherwise advised by my Doctor. Patient signature (must be 18 to sign) Date Name of parent or guardian (please print) Relationship to minor
4 CANDIDA SYMPTOM ASSESSMENT QUESTIONAIRE A: Instructions: Score each symptom between 0-10 depending on severity and the degree to which it applies to you; with 10 indicating a severe symptom and 0 indicating that the symptom does not apply to you. SYMPTOMS_ SCORE Aching Muscles... Alcohol Cravings... Anxiety... Bread/Starch Cravings... Bronchitis/Cough... Chest Pain or Tightness... Constipation... Co-ordination Problems... Depression... Disorientation/Confusion... Dizziness... Ear Infections- frequent... Emotionally over-sensitive... Eye Tearing or Burning Fatigue... Forgetfulness... Foul Smelling Body Odor... Foul Smelling Breath... Frequent Colds and Flues... Frequent Bladder or Prostate infections... Headaches... Heartburn... Hives... Hunger causes shakes or irritability... Infertility or Endometriosis... Intestinal Discomfort/Pain... Intolerant to mold... Irritability/Jumpiness... Itchy Rectum... Itchy Ears/Nose... Joint Pain... Loose Stools...
5 Menstrual Irregularities... Mood Swings... Mucus in Stools... Food Intolerances... Nasal or Sinus Congestion... Numbness/Tingling or Burning Sensations... Oral Thrush... Panic Attacks... Perfume/Chemical Sensitivities... Poor Balance... Poor Concentration... Post Nasal Drip... Psoriasis/Eczema/Skin Rashes... Sleep Disturbances... Sore Throat (frequent)... Spots in Front of Eyes... Sugar Cravings... Tobacco Smoke Intolerance... Vaginal Yeast Infections... Weak Digestion/Gas/Bloating... Weakness/Trembling... White Coating on Tongue... A. TOTAL: B. Score 5 points for each of the following questions that apply to you. More than one pregnancy... Use of birth control pills for more than six months... Antibiotics for more than three weeks... Four or more short antibiotic treatments in a two year period... Use of any steroid drug for four weeks or more in the last five years... B. TOTAL: TOTAL SCORE A &B= Mild-35 to 55 Moderate-55 to 85 Severe- 85 and higher This questionnaire is not a definite diagnosis of Candida, as other conditions may produce similar symptoms, but gives your practitioner an indication as to whether or not Candida is a possibility and make appropriate recommendations.
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Chiropractic Patient Admittance Form PERSONAL INFORMATION Last Name: Given Name: Initial: Address: City/Province: Postal Code: Home Phone: Work Phone: Cell: E-mail Address: Date of Birth (D/MM/YYYY): Male
WELCOME TO THE MILLER CHIROPRACTIC CLINIC
WELCOME TO THE MILLER CHIROPRACTIC CLINIC We are pleased that you have chosen to consult us regarding your health. In order to help us evaluate your condition thoroughly, please complete the following
PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes.
Name: DOB: PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes. TOBACCO USE: Quit Date Cigarettes Packs/Day Number of years smoked Pipe/Cigar Smokeless Tobacco Electronic or E-cigarette Secondhand
NeuroSolutions Initial Intake
NeuroSolutions Initial Intake Name Date Home Address Home Phone Cell Phone Email Address Emergency Contact & Phone Height Weight How did you hear about NeuroSolutions? What is/are your main problem(s)/symptom(s)