MISSION NATUROPATHIC CLINIC PANDOSY ST., Kelowna, BC V1Y 1V9 (250)
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1 MISSION NATUROPATHIC CLINIC PANDOSY ST., Kelowna, BC V1Y 1V9 (250) Welcome to the office of Mission Naturopathic Clinic! We are honoured that you have chosen us in your search for optimal health. Please fill out and sign the attached forms to the best of your ability, and bring them to the initial appointment. It will aid in your assessment of your present health, and facilitate in your process of healing. If you wish to cancel or reschedule you appointment; please do so 48 hours or more before your appointment. We do reserve the right to charge full cost of the visit for missed appointments, or if insufficient time is given for cancellations. We will confirm your appointment 2 days prior to your visit by phone or leave a voice mail when necessary. If you are undergoing any treatments, please do not come on an empty stomach, as this may raise some of the risks associated with therapies. If you have any questions, please call our office at (250) or speak to the reception staff. We look forward to growing with you! Note: many of our patient are sensitive to environmental substances; therefore, we ask that all patients refrain from wearing scented hairsprays, colognes, perfumes aftershaves, etc., on the day of your appointment. Payment Requirements: Appointments must be paid for at the time of service. We accept VISA, MC, Debit, and cash. Records: We keep a record of your health care services. We will not disclose your records to others unless you direct us to do so, or unless the law authorizes us to. You can obtain copies of the files for a small fee upon signing an authorization form. Please allow up to 10 working days to process the request. Insurance: Mission Naturopathic Clinic does not directly bill insurance companies. You may submit your paid invoice to your insurance company for reimbursement. We are also not a Government Funded healthcare provider, and no reimbursement will by honoured by this organization. I understand that I will have asked a Dr. Berg, Dr. Chambers, and/or Dr. Wolter of Mission Naturopathic Clinic for help and that she will help to the best of her ability. I have read and understand the above statements. Print Name Signature (signed by guardian if under-age) Date
2 Adult Intake Form Date: How did you hear about us? Name: Birth date:(m) /(D) /(Y) Last First Middle Initial Personal Health Care Number: Address: City: Province: Postal Code: Phone: Work: Home: Relationship Status: Occupation: Children: Y N Ages and Sex: Emergency Contact: Number: Height: Max weight: Weight: When: Please list any Practitioners that you are currently seeing (conventional and/or alternative) Name: Number: How long: Please list your chief concerns in order of Onset: Frequency: Severity: importance: Example: Headaches June 91 3 X week Mild/mod/severe What are your goals for this visit? Have you been given a diagnosis from other practitioners for any of these problems if so what?
3 Please fill in this form with any prescription medication, vitamin, mineral, amino acid, or other supplements that you may be taking: MEDICATION/ SUPPLEMENTATION BRAND FORM DOSAGE FREQUENCY Example: Beta Blocker Metoprolol Pill 200mg 1x day Comments: Please fill in this form with any non-prescription medication that you may be taking: MEDICATION/ BRAND FORM DOSAGE FREQUENCY SUPPLEMENTATION Example: Vitamin C Natural Factors Tablet 500mg 3 X day Comments: PAST MEDICAL HISTORY: Hospitalizations: Surgeries (year and type): Serious Illnesses/ Accidents/ Injuries (year, cause, and injury): Have you ever used general anaesthetic? Y N When? Antibiotic use? Y N When? Allergies (type and onset)? Pets (what kind and how many)? Women: Last Pap: First day of last menstrual period: Days to cycle(start to start): Days of Bleeding: Age of first menses: Menstrual difficulties: Cramping Heaviness Spotting Irregularity No period No. of pregnancies: deliveries: Complications:
4 Dental: Please note to the best of your knowledge all dental work/treatments you have undergone including fillings (type), pulled teeth, root canals, dentures, braces, retainers, accidents, other. Childhood Illnesses: Health as a child: (1) Poor to (10) Excellent Explanation: Rheumatic fever German Measles Polio Allergies Chicken pox Mumps Asthma Ear infections Skin conditions Vaccinations: (please check all that apply) ( ) DPT (Diphtheria, Pertussis, Tetanus) ( ) Booster (usually DT) ( ) Polio injection ( ) Polio oral ( ) MMR (Measles, Mumps, Rubella) ( ) HBV (Hepatitis B Vaccine) ( ) Other (flu shot, etc) Family History: Has anyone in your immediate family had any of the following: Cancer High blood pressure Diabetes Heart Disease Allergies Arthritis Epilepsy Glaucoma Mental Illness Alcoholism Stroke Obesity Other CURRENT HEALTH SYSTEMS (circle all that apply): Sleep: Number of hours: Trouble falling asleep: Y / N Trouble staying asleep: Y / N Mind restlessness: Y / N Body Restlessness: Y / N Refreshed upon waking: Y / N Energy: High Moderate Low T imes that are worse than others: Digestion: Problems with (circle all that apply): Indigestion Upset stomach Heartburn Belching GERD Nausea Bloating Gas Cramping Bowel movements: x day color: (circle all that apply): Blood Mucus Undigested foods Pain Anal itching Hemorrhoids Constipation Diarrhea Genitourinary: History of: Bladder Infections Kidney stones Other Kidney disease Sexually transmitted infection Vaginal/genital infections Pain Lung: History of: Frequent Cough Shortness of breath Smoking Frequent infections Ast hma Allergies Other Cardiovascular: History of: Heart attack Stroke Palpitations Murmur High Blood Pressure Arrhythmias Varicose veins Poor circulation Nervous System: Numbness Tingling Atrophy Pinched Nerves Pain
5 Musculoskeletal: Injury Joint Pain Muscle Pain Muscle Fatigue Spasms Muscle cramps Osteoporosis Arthritis Other Ears: Pain Ringing Deafness Frequent infections Other Nose: Allergies Sinus congestion Post Nasal Drip Surgery Other Eyes: Blurred vision Visual impairment Injury Floaters Pain Other Throat: Frequent infections Thyroid issues Loss of voice Pain Tonsillectomy Skin/Hair: eczema acne psoriasis fungal hives hair loss dryness other Toxin Exposures: (circle all) 1) Cigarette smoke: first hand second hand past present 2) Dental: silver fillings past present removed 3) Home: older than 1975 (present/past) old piping water damage/mold asbestos new carpets new cabinetry c hemical cleaners use air fresheners pets attached garage natural gas appliances 3) Food: organic % of food tap water plastics used 4) Personal: wear perfumes petroleum products use dry-cleaning use antibacterial soap deodorants fluoride 5) Occupation: (past or present) painter work with plastics work with chemicals construction industry gasoline insulation cleaning dentistry farming hair stylist esthetician with automobiles driver landscaping/planting other: 6) Live near: golf course orchard/farm mine factory 7) Other: frequent flying golfing aspartame sprays with gardening LIFESTYLE: Please indicate your consumption level of the following? NONE LIGHT MODERATE HEAVY Salt Sugar Caffeine Tobacco Alcohol Recreational Drugs Exercise Water
6 24 Hour Diet Recall: Breakfast: Lunch: Dinner: Snacks: Daily Water intake: Food Cravings: Beverages: Foods Avoided: Food Allergies: Level of Stress (circle one): High Moderate Low What are the major stressors in your life? Do you have a good support network (family, friends, groups)? What is your current living situation? Do you currently follow a (religious/spiritual) belief system? Do you: Meditate Pray Use visualizations Other relaxation techniques Hobbies? Any Further Comments or Concerns?
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MacDonald Naturopathic Medical Clinic Dr. Crista MacDonald-Werby, BHSc., ND Doctor of Naturopathic Medicine 29 Wellington Street North, Woodstock, Ontario N4S 6P4 Tel: (519) 539-7000 Dear Thank you for
Patient s Name: Birthdate: (dd/mm/yyyy) Sex: Mailing Address: Phone Number: Family Doctor or Paediatrician. How did you hear about the clinic?
Pediatric Intake Form Thank you for taking the time to fill out this form. This information is very important in order to best assess your child s needs. Patient s Name: Birthdate: (dd/mm/yyyy) Mother`s
Pediatric Intake Paperwork. Personal History
Pediatric Intake Paperwork Child s Name: Date: Address: City: Zip: Cell Phone: Work Phone: Email: Date of Birth: Social Security Number: Your occupation: Your employer: Whom to contact in case of emergency?
New Patient Information
Kairos Acupuncture, Chinese Herbs, & Bodywork LLC 262-323-9022 kairosacupuncture@hotmail.com acupuncturewestbend.com New Patient Information Name Today s Date Street Address Apt. City State Zip Preferred
Patient Name: Date: Address: Primary Care Physician: Online Website On TV In print On the radio
927 W. Myrtle St. Boise, ID 83702 (208) 947-0100 NEW PATIENT INTAKE Patient Name: Date: Email Address: Primary Care Physician: How did you hear about AVT? (Please mark all that apply) Online Website On
Dr. Andrea Gri B.Kin, ND Doctor of Naturopathic Medicine Phone: Fax: Peter Robertson Blvd, Brampton ON L6R 1T4
Dr. Andrea Gri B.Kin, ND Doctor of Naturopathic Medicine Phone: 905-793- 8868 Fax: 905-793- 8957 630 Peter Robertson Blvd, Brampton ON L6R 1T4 ADULT INTAKE FORM Name: (Last) (First) (Preferred Name) Address:
Initial Consultation
Today s Date: Initial Consultation Thank you for choosing Apollo Health and Wellness. Please take your time to fill out this form. It will help us to concentrate on areas of your health that need attention
CHILD INTAKE (Please Print Clearly)
Jeremy Hayman, ND CHILD INTAKE (Please Print Clearly) Doctor of Naturopathic Medicine Child s name (First/Last) Date of birth (M/D/Y) Sex M F Referred by Who is filling out this form (name and relation)?
Bahl & Bahl Medical Associates PATIENT MEDICAL HISTORY
Bahl & Bahl Medical Associates PATIENT MEDICAL HISTORY NAME: _ DATE: Please complete the following questionnaire as completely as possible. 1. MEDICAL HISTORY Please list all current and prior health problems,
Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION
Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION Name Date Address City State Zip Home Phone Cell Phone # Work: Email Address Occupation Employer
INSURANCE AND MANAGED CARE APPOINTMENT CANCELING POLICY
The physicians and staff of New England Dermatology & Laser Center value and appreciate your selection of our office for your skin care. We are committed to providing you with the best possible service.
New Patient Intake Form
501 Islington Street, Suite 2B Portsmouth, NH 03801 P: 603-610-8882 F: 603-463-0943 New Patient Intake Form Personal Information Today s Date Name Age DOB: Phone: H ( ) W ( ) Cell ( ) Preferred Home Work
Date of Birth Work Phone # ( ) Home Phone # ( ) Emergency Contact # ( )
Please complete the following form in order to provide us with the background information we require to ensure you receive comprehensive care. It should take 15-20 minutes. Contact Information: Name Occupation
New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
New Patient Documentation Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) Age: Birthdate: E Email: Social: Sex: Male Female Height: Weight:
HILL PARK MEDICAL CENTER PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM Address: City: Contact: State: Zip: Home Phone: Email: Work: Cell: Date of Birth: SSN#: Age: Gender: I am: q Married q In a Partnership q Separated q Divorced q Widowed q Single
Date First Name Middle Name Last Name. SSN Sex Birth Date Height Weight. Marital Status Spouse Name Number of Children. Address City State Zip
PATIENT INFORMATION Date First Name Middle Name Last Name SSN Sex Birth Date Height Weight Marital Status Spouse Name Number of Children Address City State Zip Home Phone Cell Phone Email Emergency Relation