Balance Point Health Centre
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- Marylou Paul
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1 Balance Point Health Centre Jane Goehner H.B.Sc., N.D. Jennifer Kaster B.Sc., N.D Morden Road Suite 110 Oakville, ON L6K 3W6 Phone: NEW PATIENT QUESTIONNAIRE Date: Name: Sex: M F Address: Postal Code: Home Phone #: Work#: Cell #: address: Bithdate: Age: Occupation present: - past: Marital Status: (please circle) married single divorced common law re-married How did you hear about our office? Name of Family Doctor: Primary reasons for coming to our clinic: Please state the first time you noticed the condition and describe any factors that you suspect may have played a role in its onset and progression; Please list in order of importance to you List any other health concerns: List any significant illnesses that you have had in the past including any hospitalizations: Do you exercise regularly? Y / N What do you do for exercise, how much, how often? Do you get regular screening tests done by another doctor? (Pap, blood tests, etc.) Y / N 1
2 Medications/Supplements: Please list all current and previous medications and supplements used (including antibiotics) Medications/Supplements Condition prescribed for Dose Duration of use Side Effects/Reactions Family History: Indicate where applicable if anyone in your family currently has or has had any of the following conditions: Disease/Illness Mother Father Sibling Maternal Grandparents Paternal Grandparents Heart Disease (ie. Heart attack, Congestive Heart Failure) Cancer Type: Diabetes Hypercholesterolemia Hypertension Stroke Asthma Tuberculosis Allergies Type: Kidney Disease Depression Mental Illness Psoriasis Epilepsy Osteoarthritis Alcoholism Rheumatoid Arthritis Cystic Fibrosis Eczema Age (at death) Cause of death 2
3 Please indicate your frequency of use of the following: Cigarettes/Cigars /d /wk /mo Antacids /d /wk /mo Coffee /d /wk /mo Drugs /d /wk /mo Tea /d /wk /mo Pain Relievers /d /wk /mo Pop (regular) /d /wk /mo TV (hrs) /d /wk /mo Pop (diet) /d /wk /mo Computers (hrs) /d /wk /mo Alcohol /d /wk /mo Cell phone (hrs) /d /wk /mo Microwave /d /wk /mo Did you ever smoke? Use alcohol excessively? Use recreational drugs to excess? Give details and when you quit: Do you have any allergies? (food, environmental, drug) Do you have any pets? Where do you live? Apartment House How long have you lived there? How old is your home? Have you done any home renovations recently? How would you describe the emotional climate of your home? How stressful is your work, or other aspects of your life? How well do you handle these stresses? Review of Systems For the following, place a in the space if you currently have the symptom, a P if it has been a problem in the past. Vitality Low stamina Low ambition Fatigue Energy drop during the day When? Poor Sleep Insomnia Feel unrefreshed on waking Unexplained weight gain/loss Musculo-skeletal Weakness Stiffness Aches Twitching Cramps Prone to sprains Joint Pain Joint swelling Bursitis Arthritis 3
4 Respiration Hayfever Asthma Coughing Bronchitis Shortness of breath Frequent sore throats Frequent colds/ coughs Phlegm Skin/Nails Dryness/Cracking Itching Pimples/Acne Boils Blotchy/White Patches Eczema Psoriasis Dandruff Increased pigmentation Easy bruising Spots on nails Nails brittle/split Bite nails Fungal infection of nails Eyes Watering Burning Redness Dryness Discharge Itching Double vision Blurring Sensitive to light Cataracts Glaucoma Failing vision Frequent conjunctivitis/ styes Spots in front of eyes Dark circles under the eyes Urination Dribbling Difficulty Increased frequency of urination Blood in urine Painful urination Urination at night Unable to hold urine Kidney stones Unsteady/lose balance Numbness/tingling Hair Thin Excess loss Graying Excess growth Prematurely gray Grows slowly Thinning eyebrows, underarm, pubic hair Mouth/Lips Jaw clicks Coldsores Lips cracking Canker sores Peculiar taste in mouth Bad breath Impaired taste/ smell Teeth Cavities Loose Teeth Dentures/ Bridges Root canal Sensitivity to hot/cold Bleeding gums Gum disease Grinding teeth Braces Gastro Intestinal Poor appetite Large appetite Heartburn Indigestion Belching Excessive flatulence Bloating after eating Nausea/ Vomiting Ulcer Constipation Diarrhea Hemorrhoids Cravings Strong thirst No thirst Stomach pain, burning, aching 1-4 hrs after eating Digestive problems subside with rest/ relaxation Hungry shortly after eating Anal itching Pain under right side of rib cage Fatty foods cause indigestion 4
5 Ears Loss of hearing Ringing in the ears Wax build up Frequent earaches Circulation/ Blood Dizziness Cold hands/ feet Varicose veins Low/ high blood pressure Anemia Fainting Cardiovascular Heart disease Palpitations Angina Heart murmurs Chest pain/heaviness For Males Frequent/ urgent urination Weak/ delayed urinary stream Urge to urinate several times per night Dripping after urination Lack of sex drive Impotence Difficulty attaining/ maintaining erection Painful testicles Genital rash Low sperm count Low sperm mobility History of worms/ parasites # of bowel movements per day Nose Itching Loss of smell Discharge Sneezing Sinusitis Polyps Prone to nose bleeds Neurological Headaches Migraines Forgetful Convulsions/ Seizures For Females Age at first period Length of cycle Length of period Irregular periods Bleeding between periods Menstrual clots Breast tenderness Irritability/ mood swings Bloating during period Vaginal discharge Ovarian cysts Uterine fibroids Venereal disease Breast lumps # of pregnancies # of live births Menopause Type of birth control 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? 5
6 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) 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? 6
7 PATIENT CONSENT FORM FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION Privacy of your personal information is an important part of our Clinic, while providing you with quality Naturopathic Care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We will try to be as open and transparent as possible about the way we handle your personal information. All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are trained in the appropriate use and protection of your information. Our privacy policy outlines what our Clinic is doing to ensure that: Only necessary information is collected about you We only share your information with your consent Storage, retention and destruction of your personal information complies with existing legislation, and privacy protection protocols Our privacy protocols comply with privacy legislation and standards of our regulatory body, the Board of Directors of Drugless Therapy Naturopaths This Clinic will collect, use and disclose information about you for the following purposes: To asses your health concerns To advise you of treatment options To provide health care To establish and maintain contact with you To send you newsletters and other information To remind you of upcoming appointments mailings To communicate with other treating health-care To allow us to efficiently follow-up for treatment, providers care and billing To invoice for goods and services To collect unpaid accounts To comply generally with the law To assist this clinic to comply with all regulatory requirements To comply with legal and regulatory requirements of our regulatory body, the Board of Directors of Drugless Therapy Naturopathy acting under the authority of the Drugless Practitioners Act By signing the consent section of this Patient Consent Form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal information as outlined above. It should be made clear that our Naturopathic Doctor is NOT a Medical Doctor. The Naturopath works within their scope of practice. Treatment and referral to other health practitioners is based upon assessment and laboratory testing. If conventional medical treatment is desired, it must be obtained from a licensed medical doctor. We encourage you NOT to abandon contact with your medical doctor. PATIENT CONSENT I have reviewed the above information that explains how the clinic will use my personal information, and the steps your clinic is taking to protect my information. I agree that the Naturopathic Doctors can collect, use and disclose personal information as set out above in the information about the clinic s privacy policies. Signature Print Name Date INFORMED CONSENT I,, consent to treatment from at the Balance Point Health Centre. Signature: Date: 7
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PERSONAL INFORMATION New Patient Intake Form Name Date of First Visit Address City Province Postal Code Telephone # (home) (work) E-mail Address Relationship Status Age Date of Birth (M/D/Y) Gender: female
SHEILA WOLFSON, M.Ed., C.N.S. Nutritionist and Health Counselor. 20 Main Street, Suite 300, Natick, MA Phone/Fax (508)
SHEILA WOLFSON, M.Ed., C.N.S. Nutritionist and Health Counselor 20 Main Street, Suite 300, Natick, MA 01760 Phone/Fax (508) 875-3735 HEALTH HISTORY Name Date Address Phone (H) Phone(W) Weight Height Age
Date of Birth: Age: Sex: Male Female Marital. Driver's Lic S M D. Status: Address:
Houston Weight Loss and Lipo Centers Patient Name: Address: City, State : Apt: Zip: Email*: *By providing your email address you are agreeing to communication via email. Home Phone Primary contact Work
Patient Intake Form for Acupuncture Treatment at Infinite Healing
Section A: Your Information Patient Intake Form for Acupuncture Treatment at Infinite Healing Last Name: First Name: Middle Initial: Mailing Address: _ City: Postal Code: E-mail: Birth date: M D YR Age:
What do you feel are your child s strengths at this time?
PEDIATRIC MEDICAL QUESTIONNAIRE Our ability to draw effective conclusions about your present state of health and how to improve it depends, to a significant extent, on your ability to respond thoughtfully
Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6
Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6 These questions are general screening questions designed to identify areas where additional attention may be required. Please bring
Name: Date of birth: Address: City: State: Zip: Phone: (day) (evening): (cell): address: Occupation: Who referred you/how did you hear about us?
Name: Date of birth: Address: City: State: Zip: Phone: (day) (evening): (cell): Email address: Occupation: Who referred you/how did you hear about us? Your primary health care provider: Phone: Emergency
BROADWAY SPORTS & INTERNAL MEDICINE, P.S TH AVE NE SUITE 202 BELLEVUE, WA P: F:
BROADWAY SPORTS & INTERNAL MEDICINE, P.S. 1600 116 TH AVE NE SUITE 202 BELLEVUE, WA 98004 P: 206 215-2288 F:206 215-2289 MEDICAL HISTORY QUESTIONNAIRE Date Name Date of Birth HT WT Current Medical Complaints
HEALTH HISTORY QUESTIONNAIRE
1525 S. Alafaya Trail Unit 105 / Orlando, FL 32828 T: 407-282-4449 F: 407-282-4438 www.synergyspineinjury.com HEALTH HISTORY QUESTIONNAIRE Name: Date: Address: City: State: Zip: S.S. #: Cell Phone: Home
Address: City: Postal Code: Emergency Contact: Phone# Relationship: Who may we thank for referring you to this office?
CLAYTON PARK CHIROPRACTIC CENTRE INC. Suite 11-117 Kearney Lake Road Halifax, Nova Scotia B3M 4N9 (902) 443-5669 phone (902) 443-9419 fax info@claytonparkchiro.ca For Office Use Only: Bilaterals L R PERSONAL
S u n s h i n e. Health Care Center N 94th Drive, Ste. C-4 Peoria, AZ ADULT INTAKE FORM
ph (623) 266-1722 fax (623) 266-1746 13660 N 94th Drive, Ste. C-4 Peoria, AZ 85381-4841 www.sunshinehealth.net info@sunshinehealth.net ADULT INTAKE FORM Name: Date: Date of birth: Age: Gender: Address:
Rockwood Natural Medicine Clinic
Rockwood Natural Medicine Clinic 9755 N. 90 th St., Suite A-210 Scottsdale, Arizona 85258 480-767-7119 Date: Name: Age: Sex: M F Are you: Married Separated Divorced Widowed Single How did you hear about
Adult Health History Summary
Adult Health History Summary Name Age Date of Birth Address City Province Postal Code Phone (home) (cell) Occupation Email May we contact you via email? YES NO Emergency Contact Phone # How did you hear
MenoChat. City State Zip Code. Employer Job Title. Primary Care Provider Phone: History. Desired Outcome:
MenoChat Patient Health History Questionnaire Patient Name (last, first, MI): How did you hear of MenoChat? Address City State Zip Code Home Phone #: Cell Phone #: Male or Female Marital Status Email Employer
Bend Surgical Associates. Michael J. Mastrangelo, MD, FACS. Medication Name Dosage Frequency Medication Name Dosage Frequency
Bend Surgical Associates Michael J. Mastrangelo, MD, FACS PATIENT NAME: DATE F BIRTH: MEDICATINS Please list all of your current prescription, non-prescription medications, vitamins, minerals, and supplements.
Margie Petersen Breast Center
Medical History Questionnaire Name: Sex: Female Male Last First Middle Date of Birth: Age: Birth Place: Mother s Birth Name: Social Security #: - - Marital Status: Single Married/Partnered (how long) Divorced
REDROCK MEDICAL GROUP INITIAL HISTORY AND PHYSICAL
REDROCK MEDICAL GROUP INITIAL HISTORY AND PHYSICAL NAME: BIRTH DATE: AGE: SEX: M F OCCUPATION: RACE: WHO REFERRED YOU TO OUR OFFICE? _ WHAT IS YOUR MAIN COMPLAINT? HOW LONG HAS THIS BEEN A PROBLEM? IS
Integrative Consult Patient Background Form
Let Us Know More - So We Can Help Thank you for choosing to schedule an integrative medicine consultation with UC Health. To help us meet your needs during your visit, please take some time to sit in a