Family Naturopathic Clinic
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- Kelly Day
- 6 years ago
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1 Mark Orbay, B.Sc., N.D. Doctor of Naturopathic Medicine 265 Carling Avenue, Suite 610 Tel: (613) Fax: (613) Name: Phone (Home) Address: (Office) Date of Birth: / / Age: (Month) (Day) (Year) Birth Place: Marital Status: Occupation: Name of spouse: Name of family Medical Doctor: Who referred you to the clinic? Present weight: rmal weight: When were you last this weight? What is your chief concern about your health? If this is a chronic condition, how long have you had this condition? Who diagnosed your illness? When was the diagnosis made? What specialists have you seen? (Please also indicate year of consultation) How has your condition(s) been treated until now? What else would you like to see changed in your health? (Indicate how long you have had each of these conditions.) How long has it been since you have been totally well? 1
2 Previous History: Measles Gallstones Bowel Disease Mumps High Blood Pressure Rashes Scarlet Fever Pleurisy Malaria Whooping Cough Arthritis Gonorrhea Croup Rheumatism Chlamydia Pneumonia Gout Asthma Tuberculosis Genital Herpes Constipation Mononucleosis Hay fever Diphtheria Ear infections Chicken pox Candida Depression Allergies Hypoglycemia Sinusitis Colds and Flus Swollen glands Eczema Cancer Parasites Diabetes Kidney conditions Hypothyroidism Hyperthyroidism Angina Shingles Stroke TMJ Dysfunction Urinary Tract Infection Alcoholism Anemia Back and Neck Pain Chronic fatigue Fibromyalgia Dental Disorders Meningitis Jaundice Digestive disorders Crohn s Disease Stomach ulcer Celiac s disease Insomnia Varicose Veins Ringing in ears/tinnitus Trauma Environmental Illness Eye Disorders Headaches Hemorrhoids Hepatitis Infertility Learning Disorders Lyme s disease Obesity Osteoporosis Other Were any of the above severe? If so give age, severity, and duration. Do you donate blood on a regular basis? Yes Have you donated blood in the past? Yes Infectious Disease Status: Did you receive a blood transfusion in Canada between 1980 and 1990? Yes Do you have hepatitis A, B, or C? Yes If yes, which one(s)? Are you HIV positive or do you have AIDS? Yes Are you in close contact with an infected person who has one of the above diseases? Yes List any other infectious diseases that you have 2
3 Describe your general state of health as a child Describe your general state of health as a teenager Surgeries: Please indicate the type of surgery, date, and where it was performed. Accidents: Please indicate the injuries sustained, severity, when they occurred, and any necessary treatments Family History: Please indicate the age of all your immediate family members living (L = living) and indicate the age at which any member became deceased (D = deceased) Father L D Mother L D Brothers L D Sisters L D L D L D L D L D Indicate the number of relatives: grandparents, parents, brothers, or sisters who have or had the following diseases. Diabetes Cancer Heart Disease Mental Illness Alzheimer s Disease Tuberculosis Arthritis High Blood Pressure Allergies Kidney Disease Stomach Disorders Additional Male History: Have you ever had any prostate problems? Yes If yes, please describe. Have you ever experienced any bladder problems? Yes Please list any other male conditions you have: 3
4 Additional Female History Age of first period/menses Are your menses regular? Do you experience PMS symptoms? Yes If yes, what do you experience? Age of cessation of menses Irregular? Have you experienced fibrocystic disease of the breast? Yes Have you ever had uterine fibroids? Yes Do you have recurring vaginal infections? Never Rarely Frequently More than three times a year Number of Children Ages: Number of pregnancies Deliveries Miscarriages Abortions Were there any complications associated with the above? Please list any other female conditions that you have Medications: List all the prescribed medications you are currently taking. Indicate the drug name, dosage, frequency, and how long you have been taking it. List all prescribed medications that you have taken in the past for any period of time longer than three months. List any prescribed medications that you have had a bad reaction to in the past. Indicate the drug name, when you took it, and the adverse reaction you had. 4
5 How many courses of antibiotics have you had in the past ten years? Have you had a bad reaction to any antibiotics? Yes List any over-the-counter medications you take (i.e. Aspirin, Tylenol, Tums ) Indicate whether you take them rarely, occasionally, frequently, or daily. Have you ever used recreational drugs? Yes Do you currently use recreational drugs? Yes (If yes, indicate type and frequency of usage). Have you ever had a severe reaction from a vaccination? Yes (If yes, explain vaccination type, when it was administered, and the reaction). List all food supplements you are presently taking. Indicate the total dosage taken daily (i.e. If you take 2 tablets of vitamin C 500 mg/day, the total is 1000mg.) Lifestyle: How many cups/bottles/glasses do you drink of the following on an average day? Coffee Tea Water Milk (2%) Milk (skim) Fruit Juice Soft Drinks (regular) Soft Drinks (diet) Vegetable Juices Herbal Tea Beer Wine Liquor How often would you have an alcoholic beverage per week? Do you smoke? Yes (How many cigarettes/day? Cigars/day? ) Have you ever smoked? For how long? Does anyone else smoke in the household? Yes Does anyone smoke in your workplace? Yes 5
6 List any work-related or household environmental concerns and hazards How many hours do you work each week? What do you do for exercise? (Indicate type of exercise, and frequency per week) What do you do for recreation? What are your hobbies? How many hours per day do you watch television and surf the Internet? What, if any, pets do you have? How many hours of sleep do you get on average? When was your last vacation? How long was it? What level of personal stress (rated as a percentage) are you currently experiencing in each of the following areas? Financial Job related Interpersonal Marriage Health Family members Spiritual Unfulfilled expectations Other Do you participate in any religious group? Are you an active participant? Thank you for taking the time to fill out the requested information. It will help greatly in our study of your present health concerns and will assist us in choosing an appropriate direction for your restoration of health. 6
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
MEDICAL HISTORY (To be filled in by patient)
MEDICAL HISTORY Reason for Visit or Chief Complaint: Referred By: Present Illness: (To be filled in by Physician) I. Have you had any reactions, allergies or bad effects from any of the following: Serum
Name Age DOB Sex M F Your relationship status: Single Married Life partner Widowed Address
Today s Date Contact Information Name Age DOB Sex M F Your relationship status: Single Married Life partner Widowed Address Phone numbers and E-mail (please check numbers to call or leave a message) Home
NEW PATIENT INFORMATION *All information provided is kept in strict confidence
NEW PATIENT INFORMATION *All information provided is kept in strict confidence Name: Date: Address: Telephone: (home) (cell) (work) E-mail: Emergency contact: (name) (relationship) telephone: (home) (cell)
Initial Consultation
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Liver Health: Do you have liver problems? Yes No If so, please specify:
Medical History General Last Name: First Name: Date of Birth: Age: Contact Number: Are you in good health to the best of your knowledge Medical Information: Please list any physicians you see and their
Patient Information. How did you hear about the BIHC: If you were referred, please state by whom: If yes, by whom: Date of last visit: DD/MM/YYYY
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Adult Naturopathic Intake Form
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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
Date of Birth: Age: Sex: male female. Weight: Height: Address: Parents: Mother s Phone: (home) (cell) (work) Mother s
*All information provided is kept in strict confidence Child s Name: Date: Date of Birth: Age: Sex: male female Weight: Height: Girls: Age at first period: Address: Parents: Mother s Phone: (home) (cell)
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Date First Name Middle Name Last Name. SSN Sex Birth Date Height Weight. Marital Status Spouse Name Number of Children. Address City State Zip
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Dr. Fawn Shaffer, DC 565 McElhattan Drive Lock Haven, PA (570)
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Surgical History Please list all operations and dates:
1 General Information *Please complete in blue or black ink only* Name: Date: Address: City: State: Zip Code: Date of Birth: Email: Telephone: (Cell) (Home) (Work) Referred by: Occupation: Primary Doctor: