Naturopathic Family Physician
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- Sabrina Weaver
- 6 years ago
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1 Are you ready for a new way to look at your health and your life? Are you looking for a dynamic medicine that treats YOU rather than your symptoms? Welcome to the and our private medical practice that incorporates Naturopathic medicine, Acupuncture, Bowen therapy and more. We practice on the top floor of a heritage house that is full of art, and exudes a relaxing and healing atmosphere. The philosophy of Naturopathic medicine is based on six vital concepts: 1.) The Healing Power of Nature 2.) First Do No Harm 3.) Identify and Treat the Cause 4.) Doctor as Teacher 5.) Prevention 6.) Treat the Whole Person As Naturopathic doctors, we practice multiple disciplines. These include clinical nutrition, lifestyle counseling, botanical medicine, homeopathy, and physical medicine. We are also certified in Acupuncture and IV therapy, have special training in the use of Bio Identical Hormones, have our prescribing rights and practice Traditional Oriental Medicine as well as Bowen Therapy. Working towards optimal health is a lifestyle. Not only do we aim to eliminate and prevent disease, we allow ourselves the experience to thrive in life on many levels. The process of achieving better health is not a quick fix. It includes a deep look into one s lifestyle, goals, challenges; a journey that takes time and dedication. We are honored to work with you in pursuit of your optimal health and I look forward to helping you reach your full potential. The initial visit is approximately 60 minutes. Follow-up visits will vary in length, depending on the complexity of the issues and the type of treatment applied. Attached to this letter is your health questionnaire. We would like you to take time filling it out in your home, without any distractions. Please read the consent form and fee schedule thoroughly. If you have extended health care coverage for Naturopathic medicine, you will be responsible for reimbursement. Thank you for your interest in health and we look forward to working with you. Sincerely, Dr. Sarah Nyrose, ND (locum for Dr. Krista Braun, ND until Fall 2017) & Dr. Briana Peddle, ND
2 PEDIATRIC INTAKE FORM (6-12 years) Name: Date: Age: Date of Birth: / / Female: Male: Mother's name: Father's name: Address: City: Province: Postal Code: Phone # (home): ( ) Parent s # (work): ( ) Parent s address: How did you hear about our clinic? HEALTH HISTORY QUESTIONNAIRE Birth place: Birth time: Birth weight: What are your child's most important health problems? List as many as you can in order of importance: Does your child have a contagious disease at this time? Y / N If yes, what? Previous Illnesses Rheumatic fever Y / N German measles Y / N Chicken pox Y / N Measles Y / N Tonsillitis Y / N approx. # of times: Ear infections Y / N approx. # of times: Other Y / N list: Has your child had any of the following tests? When Where Electroencephalogram (EEG) Psychological evaluation Hearing tests Speech/Language tests
3 Hospitalizations/ Surgeries/ Injuries What hospitalizations, surgeries or injuries has your child had? Immunizations U Up to Date P Partial N Not done Pre-School HBV (Hepatitis B) HAV (Hepatitis A) Hib (Hemophilus influenza type B) IPV (Polio) Varicella (chicken pox) DTaP (Diphtheria, Tetanus, Pertussis) MMR (Measles, Mumps, Rubella) PCV (Pneumococcal Bacteria) School Age Td (Tetanus, Diphtheria) MCV4 (Meningitis) Other Influenza Other (Please list): Reactions to Immunizations? Allergies Is your child hypersensitive or allergic to: Any drugs? Any foods? Any environmentals? Breast fed? how long? Formula? milk / soy Typical Food Intake Breakfast: Lunch: Dinner: Snacks: To Drink: Medications/Supplementation Please list any prescription medications, over the counter medications, vitamins or other supplements your child is taking: 1) 5) 2) 6) 3) 7)
4 4) 8) Habits Main interests and hobbies: Day Care School Home school Grade Level: Does your child watch TV? Y / N How many hours per day? Does your child read? Y / N How many hours per day? Does your child play video games? Y / N How many hours per day? Does your child play sports? Y / N How many hours per day? Are there any pets in the home? Y / N What kind? Anyone in the home smoke? Y / N Social History Whom does the child live with? Are the parents divorced / separated? Y / N If so, what are the arrangements made with the other parent (eg. visitation etc.)? List the age and gender of siblings. Indicate half, step or deceased as applicable CONTEXT OF CARE REVIEW What three expectations do you have from this visit to our clinic? What long term expectations do you have from working with our clinic? Is there any information about your child's health that you would like to add? What expectations do you have for your child from working with our clinic?
5 REVIEW OF SYSTEMS Y= Yes N= No, never P=signification problem in the past S= Sometimes a problem MENTAL/ EMOTIONAL Mood Swings Irritability Hyperactivity Introvert/extrovert Motion/car sickness Anxiety/nervousness Cries easily Unusual fears Sleep problems Nightmares ENDOCRINE Heat/cold intolerance Fatigue Excessive thirst Excessive hunger Low blood sugar High blood sugar SKIN Rashes Eczema, Hives Acne, Boils Itching HEAD Headaches Head Injury Dizzy spells High fevers EYES Glasses or contacts Tearing or dryness Eye pain/strain EARS Earaches Impaired hearing NOSE AND SINUSES Frequent colds Nose Bleeds Stuffiness Hayfever Sinus problems Loss of smell MOUTH AND THROAT Frequent sore throat Canker sores Breath odor RESPIRATORY Cough Wheezing Asthma Bronchitis CARDIOVASCULAR Heart disease Murmurs URINARY Frequent urination Bed wetting GASTROINTESTINAL Belching/passing gas Stomach aches Constipation Diarrhea Bowel Movements How often? MUSCULOSKELETAL Joint pain/stiffness Muscle spasms/cramps Broken bones BLOOD/PERIPHERAL VASCULAR Anemia Easy bleeding/bruising Thank you! We are looking forward to working with you and your child!
6 Informed Consent and Request for Naturopathic Medical Care and Acupuncture As a patient I have the right to be informed about my health condition(s) and recommended treatment. This disclosure is to help me become better informed so that I may make the decision to give, or withhold, my consent as to whether or not to undergo care with the naturopathic doctor, having had the opportunity to discuss the potential benefits, risks and hazards involved. I,, hereby request and consent to examination and treatment with Naturopathic Medicine and acupuncture by the primary naturopathic doctor (please ): Dr. Sarah Nyrose, ND (locum for Dr. Krista L. Braun, ND until Fall 2017) Dr. Briana Peddle, ND I can request that students and preceptors not be included in my evaluation and treatment. I understand that I have the right to ask questions and discuss to my satisfaction with the naturopathic doctor, and/ or with the allied health care provider, providing backup: 1.) My suspected diagnosis(es) or condition(s) 2.) The nature, purpose, goals and potential benefits of the proposed care 3.) The inherent risks, complications, potential hazards or side effects of treatment or procedure 4.) The probability or likelihood of success 5.) Reasonable available alternatives to the proposed treatment procedure 6.) Potential consequences if treatment or advice is not followed and/ or nothing is done I understand that a Naturopathic evaluation and treatment may include, but are not limited to: Physical exam (including general, musculoskeletal, EENT, heart and lung, orthopedic and neurological assessments) Common diagnostic procedures (including venipuncture, pap smears, diagnostic imaging, laboratory evaluation of blood, urine, stool and saliva) Soft tissue and osseous manipulation (including naturopathic/osseous manipulation of the spine and extremities) Dietary advice and therapeutic nutrition (including use of foods, diet plans, nutritional supplements and intra-muscular vitamin injections) Botanical/ herbal medicines (prescribing of various therapeutic substances including plant, mineral, and animal materials). Substances may be given in the forms of teas, pills, creams, powders, tinctures which may contain alcohol, suppositories, tropical creams, pastes, plasters, washes or other forms Homeopathic remedies (highly diluted quantities of naturally occurring substances): oral, IV or intramuscular use Hydrotherapy (use of hot and cold water) Counseling (including but not limited to visualization for improved lifestyle strategies) Bowen therapy (gentle physical therapy) Pharmacy prescription IV therapy: vitamins and immune boosting remedies bypass the sometimes inefficient absorption of the digestive system. This is especially useful in treating conditions such as colds and the flu, chronic fatigue, chronic digestive problems and stress. Potential risks: there is a low risk of allergic reaction, bruising, swelling, and or pain. The scope of practice of acupuncture is outlined below. I understand that Traditional Oriental medicine and Acupuncture evaluation and treatment may include, but are not limited to: Acupuncture (insertion of specialized disposable stainless steel sterilized needles through the skin into underlying tissues at specific points on the bodies surface) Moxa (indirect or direct burning of herbal material in the form of a loosely compacted herb or stick Cupping (used to relieve symptoms of pain and chest congestion in which glass cups are placed on the skin with a vacuum created by heat)
7 Dietary advice (based on Traditional Oriental medicine theory) Herbs (use of herbal formulas in the form of teas, powders, pastes, and plasters, which may be taken internally or used externally as a wash. Formulas may include shells, minerals, and animal materials) Potential risks: Pain, discomfort, blistering, minor bruising, discoloration, infections, burns, itching, loss of consciousness and deep tissue injury from needle insertions, topical procedures, heat, hydrotherapies; allergic reaction to prescribed herbs, supplements; soft tissue or bony injury from physical manipulation; aggravation of pre-existing symptoms. Potential benefits: Restoration of the body s maximal and optimal functioning capacity, relief or pain and other symptoms of disease, assistance with injury and disease recovery, and prevention of disease or its progression. Notice to pregnant women: All female patients must alert the provider if they have confirmed or suspect pregnancy as some therapies prescribed could present a risk to the pregnancy. Notice to individuals with bleeding disorders, pace makers, and/or cancer: For your safety it is vital to alert your provider of these conditions. Please Initial: I understand that Dr. Krista L. Braun, ND (Dr. Sarah Nyrose, ND) and Dr. Briana Peddle, ND, are currently licensed to prescribe prescription medications, excluding Schedule F Drugs (narcotics). I understand that Dr. Krista L. Braun, ND (Dr. Sarah Nyrose, ND) and Dr. Briana Peddle, ND, are not psychologists or psychiatrists. Counseling services are provided for the support of improved lifestyle strategies. I recognize that even the gentlest therapies may potentially have complications in certain conditions, in very young children, in the elderly, or in those on multiple medications. Hence, the information I have provided is complete and inclusive of all health concerns including the possibility of pregnancy, and all medications, including over the counter drugs (eg. Tylenol) and supplements. I do not expect Dr. Krista L. Braun (Dr. Sarah Nyrose, ND) and/or Dr. Briana Peddle to be able to anticipate and explain all of the risks and complications, and I wish to rely on the provider to exercise all judgment during the course of the procedure based on the known facts. I also understand that it is my responsibility to request that my ND explain therapies and procedures to my satisfaction. I further acknowledge that no guarantee of services have been made to me concerning the results intended from any treatment provided to me. By signing below I acknowledge that I have been provided ample opportunity to read this form or that it has been read to me. I understand all of the above and give my oral and written consent to the evaluation and treatment. I intend this as a consent form to cover the entire course of treatments for my present condition and any future conditions for which I seek treatment. Printed Name of Patient Signature of Patient Printed Name of Guardian Signature of Guardian
8 Fee Schedule (Please Note: The fee schedule may change at anytime and is in line with the fee recommendations stated by the British Columbia Naturopathic Association). First office visit (60 minutes) $170 Pediatric first office visit (0-12yrs) (45 minutes) $105 Return visit (adult) 30 minutes $90 45 minutes $ minutes $120 Women s Wellness Exam (including PAP smear) (60min) $120 Acupuncture Session $100 Special Pricing for Acupuncture 2 nd Acup visit of the week $55 Weekly $80 Return visit (child) (30 minutes) $90 Bowen Therapy Session $100 IV Push (30min) $90 Brief Visit (15min) $45 Phone AND consultations fees same as return visit fees. Lab work and supplements prescribed by your naturopathic doctor are an additional cost and not included in the visit fee. Please note: The patient is responsible for payment at the time of service, unless previously arranged by your naturopathic doctor. A portion of your visit may be claimed through your extended health coverage, or if you have premium assistance through MSP. You will be billed for phone consultations and correspondence, except those regarding questions about prescribed treatments and conditions already being treated. Because fees are subject to change, please confirm at time of booking. Cancellation policy: Any appointments cancelled with less than 24 hours notice will be subject to a cancellation fee, as per policy instated by the. * I have reviewed the above fees and understand that I am responsible for payment at the time of service, unless previously arranged by Dr. Braun (Dr. Nyrose) or Dr. Peddle. I also understand that I will be billed for phone consultations and correspondence. I also understand that I will be charged for appointments cancelled without 24 hours notice, except in cases of emergency. Signed: Date:
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Dr. Kelly Gillis ND BPHE (Lic. 3095) Doctor of Naturopathic Medicine Naturopathic Pediatric Intake Form (Child 0-13 yrs) Child s name: Parent/Guardian s name(s): Address: Age: Date of Birth: DD/MM/YYYY
Pediatric Intake Form
Pediatric Intake Form Welcome. This intake will help us to discover the root cause of your health concerns. If any of these questions are difficult for you to answer, please let Dr. McAllister know. Please
MEDICAL DATA SHEET For Patients 18 years of age and older
MEDICAL DATA SHEET For Patients 18 years of age and older NAME: DATE: / / AGE: DOB: / / 1. What is the main reason you are seeking a physician s advice? 2. Please list all allergies: Drug Allergies: Other
New Patient Intake Form
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
ARGYLE NATURAL HEALTH CENTRE NATUROPATHIC INTAKE FORM. Full Name: (First) (Middle) (Last)
ARGYLE NATURAL HEALTH CENTRE NATUROPATHIC INTAKE FORM Full Name: (First) (Middle) (Last) Date of Birth: / / Age: Sex: F M dd mm yy Marital Status: Single Married Common-law Divorced Widowed Street Address:
COMPREHENSIVE NEW PATIENT QUESTIONNAIRE
What brings you in today? What do you prefer to be called (nickname)? Please list all of your medical conditions. 1. 5. 2. 6. 3. 7. 4. 8. What surgical or medical procedures have you had in the past? 1.
Medical History Form
Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart
o Ongoing management of my
Today s date: Patient s Name Date of Birth / / Age Gender Sex assigned at birth Parent s name Parent s name Please indicate the type of care that you are seeking for your child: o Primary management of
Paediatric Intake (0-12) George Tardik B.Sc, ND- Naturopathic Doctor
Paediatric Intake (0-12) George Tardik B.Sc, ND- Naturopathic Doctor Name Date of birth Sex M F Date Address Phone h w other May we leave messages relating to your visits? Y N Which one? Emergency contact:
tel: (905) fax: (905) CHILD Questionnaire (to be answered by the mother if possible)
70 Queen St. S. Mississauga Ontario L5M 1K4 tel: (905) 826-1768 fax: (905) 286-5856 CHILD Questionnaire (to be answered by the mother if possible) Child s Name: Parents: Address: Phone: (day) (eve) Parents
PATIENT INFORMATION FORM (WOMEN ONLY)
PATIENT INFORMATION FORM (WOMEN ONLY) Name: Age: Sex: Birthdate: / / SS # A. Describe briefly your present symptom(s) or the reason(s) for seeing the doctor today: B. Name all illnesses or conditions for
CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.
II. Goal and Expectations (Please tell us your goals and expectations.) III. Childhood Illnesses (Please check those illnesses that you have had.
Natural Health and Wellness Center The path to a healthier, more vital you. PEDIATRIC HEALTH HISTORY QUESTIONNAIRE SUCCESSFUL HEALTH CARE AND PREVENTION ARE ONLY POSSIBLE WHEN THE PROVIDER HAS A COMPLETE
Benna Lun BSc(Hons) ND Naturopathic Doctor
Today s Date: WHO IS FILLING OUT THIS FORM? Name (Please print) Relationship to child PATIENT INFORMATION Name: First name Middle name Last name How would you like us to address the child? Date of Birth
WELCOME. Thank you for your interest in acupuncture and Oriental medicine. Our goal is to help you achieve your best health and wellness naturally.
WELCOME Thank you for your interest in acupuncture and Oriental medicine. Our goal is to help you achieve your best health and wellness naturally. Before your Visit: You should eat a light meal or snack
New Patient Information
Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
Student Full Name: Date of Birth:
Student Medical Form This form is to be completed for new students upon admission, and returning students prior to starting grades 3, 6, and 9. Students participating in athletics must complete form every
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)?
GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT
GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT Full name: Date: Telephone Number: Age: Address: Email address: CHIEF COMPLAINTS(List the problems about which you came to see the doctor) 1) 2) 3)
Welcome to About Women by Women
Welcome to About Women by Women Today s Date New Patient Questionnaire Name: Birth Date: / / Home Phone: Address: Cell Phone: Work Phone: Occupation: Employer: Marital Status: Married Living w/ Partner
Naturopathic Patient Intake
* Evolve 5th Avenue Calgary Place Suite 116, 414-3rd Street SW Calgary, AB, T2P 1R2 E: 5thAve@evolvechiro.ca F: 403.719.0356 Evolve 8th Avenue Watermark Tower Suite 110, 530-8th Avenue SW Calgary, AB T2P
Gardasil Network Development Project GARDASIL VACCINE QUESTIONNAIRE
Questionnaire ID Gardasil Network Development Project GARDASIL VACCINE QUESTIONNAIRE Answering this questionnaire is voluntary. Personal identifying information will not be shared with anyone outside of
PATIENT INFORMATION Please print clearly and complete all blanks
PATIENT INFORMATION Please print clearly and complete all blanks DATE: REFERRED BY: SEX: NAME: LAST FIRST MIDDLE BIRTHDATE: MAILING ADDRESS: CITY STATE ZIP TELEPHONE: CELL PHONE: WORK NUMBER: SS # MARITAL
Patient Intake Form LEGAL NAME: LAST FIRST MI I PREFER TO BE ADDRESSED AS BIRTHDATE: AGE: SEX: F ADDRESS: CITY: STATE: ZIP: HOME PHONE: WORK: CELL:
Patient Intake Form LEGAL NAME: LAST FIRST MI I PREFER TO BE ADDRESSED AS BIRTHDATE: AGE: SEX: F M ALLERGIES TO MEDICATIONS: ADDRESS: CITY: STATE: ZIP: HOME PHONE: WORK: CELL: MAY WE LEAVE A MESSAGE? YES
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
Enrollment Application
Enrollment Application Please complete this application and return to: 11040 Colorado Blvd. Thornton, CO 80233 If you have any further questions, please contact us at: Fax: 303-920- 2147 Phone: 303-920-2142
Adult Health History
Carriage House Medicine Jennifer C.Reid, N.D. 27530 SE Division Dr. Bldg C Gresham, OR 97030 (503) 492-9427 Adult Health History SUCCESSFUL HEALTH CARE AND PREVENTATIVE MEDICINE ARE ONLY POSSIBLE WHEN
Pure Health Natural Medicine
Pure Health Natural Medicine Female Intake Date: Personal Information Name: (first, last) Maiden: Preferred Name: Sex: M F Date of Birth: Age: Street Address: City: State: Zip: E-mail Home Phone: Cell
Signature: Today s date: (Parent or Guardian if a minor)
487 Davie St. Vancouver, V6B 2G2 Ph:604-697-0397/ Fax:604-697-0883 PERSONAL INFORMATION Name Date of First Visit Address City Province Postal Code Telephone # (home) (work) E-mail Address Relationship
1. Have you ever had or now have: 2. Have you ever had or now have:
1. Have you ever had or now have: 2. Have you ever had or now have: Yes No Please Check each item no blanks CARDIOVASCULAR Yes No Often Seldom 1. Chronic or frequent colds 1. Shortness of breath with normal
An Hao Natural Health Care Clinic 2348 NW Lovejoy St. Portland, OR
Edythe Vickers, N.D., L.Ac. Loren Lubin (Resident) Rachel Eppinga, N.D., L.Ac. Heather Krebsbach, N.D., L.Ac. Angela Read, L.Ac. Patient Intake Form Page 1 An Hao Natural Health Care Clinic 2348 NW Lovejoy