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1 Dr. Gayle Maguire, BSc, ND Active Sports Therapy Calgary, AB. Ph: (403) Naturopathic Health Questionnaire Welcome to Naturopathic medical care at Active Sports Therapy! We know that your health is influenced by many factors. Your questionnaire provides valuable information which helps us to understand the underlying causes of your health concerns. Fill out the questions to the best of your ability and bring the form in with you to your first visit to our clinic. GENERAL CONTACT INFORMATION Name: (last name) (first name) (middle initial) Age: Gender: Female Male Date of Birth: / / Address: (street address) (city) (province) (postal code) Telephone: Home Work Cell May we leave messages on your phone line? Preference (circle all applicable): Home/ Work/ Cell Fax: Occupation: How did you hear about this clinic? Emergency Contact: (name) (relationship) (telephone) Primary physician? Last physical exam? (name) (telephone) (month) (year) Please complete the following questions: MEDICAL HISTORY What are the most important health concerns that you are seeking treatment for or are currently being treated for? List as many as you can in order of importance. 1) 2) 3) 4) 5) Please list any prescription medications, over the counter medications, vitamins or other supplements you are taking, the dosage and the reason for using them: 1) 2) 3) 4) 5) Please list any allergies or sensitivities (drugs, foods, environmental) that you are aware of?
2 Please list all significant conditions, concerns or traumas (i.e. surgery) you have had: year? is it still affecting you? year? is it still affecting you? year? is it still affecting you? Environmental Exposure Have you ever been exposed to toxic chemicals, solvents, sprays, pesticides, herbicides, heavy metals (lead, mercury, cadmium, arsenic, etc) while at work, home or travelling? Y N Do you have, or have you ever had, mercury dental fillings? Y N Do you have any surgical implants or piercings (medical, cosmetic) Y N Have you been vaccinated? Y N. Have you ever reacted to any vaccinations? Y N How many times have you been on antibiotics in your life? When was the last time? Do you have a history of drug or alcohol abuse? Y N Have you experienced violence, neglect or sexual abuse? Y N Is it ongoing? Y N Please list the most significant events that have impacted your life? 1. year? 2. year? 3. year? 4. year? 5. year? TYPICAL FOOD INTAKE Breakfast: Lunch: Dinner: Snacks: Cravings: Aversions: Do you add salt to your food? Y N Do you drink coffee? Y N How many cups/day? Water intake per day? litres Other Beverages: Do you have any dietary restrictions? GENERAL Weight lbs. Max weight lbs, when? Height Blood Type Rate your energy level between: (low) (high) When during the day is your energy the best? worst? Rate your stress level between: (low) (high) What are sources of stress in your life? 2
3 How do you cope with stress? FAMILY HISTORY Please check any of the following conditions that have occurred in your family (grandparents, parents, siblings). I don t know my family medical history Diabetes Cancer Multiple Sclerosis Osteoporosis Seizures Arthritis Asthma Parkinson s Thyroid Condition Kidney Disease Alzheimer s Eczema Heart Disease Mental Illness Addiction Other REVIEW OF SYSTEMS Please check the box if you are currently experiencing the symptom, or have in the past. Mental/Emotional: Mood swings. Anxiety or nervousness. Poor concentration. Memory Problems. Depression. Anger. Endocrine: Thyroid disease. Heat or Cold Intolerance. Diabetes. Sugar Sensitivities. Fatigue. Weight loss/weight gain. Tend to be a night person Slow starter in the morning Difficulty relaxing Feel wired Clench/grind teeth Dizzy when stand too quickly Perspire easily Afternoon crash Immune: Chronic Infections. Chronic swollen glands. Slow wound healing. Frequent colds. Skin: Rashes. Eczema, Hives. Acne, Boils. Itching. Night sweats Dryness Nail changes Other changes/findings: Head: Headaches. Migraines. Head Injury Eyes: Visual disturbances. What kind? Dryness Sun sensitivity Ears: Earaches. Impaired Hearing. Dizziness. Ringing in Ears. Nose and Sinuses: Nosebleeds. Seasonal Hay fever. Sinus problems. Loss of smell. Mouth and Throat: Frequent sore throat. Sore tongue/lips. Swollen glands Tonsils removed. Loss of taste. Hoarseness Respiratory: Cough. Wheezing. Asthma. Bronchitis. Emphysema. Chronic Phlegm. Shortness of breath Cardiovascular: Heart disease. High/Low Blood Pressure. Palpitations. Arrhythmia. High Cholesterol. Ankle swelling Past EKG Peripheral vascular: Cold hands/feet Varicose veins Leg cramps Gastrointestinal: Heartburn. Belching or Passing Gas. Change in thirst.indigestion Change in Appetite. Constipation. Diarrhea. Abdominal pain Undigested food in stool Black tarry stool Clay coloured stool Floating stool Stool that sticks to toilet bowl Hemorrhoids Bloating Bad breath Sleepy after meals Better if don t eat Upset by greasy foods Sea or motion sickness Poor tolerance to alcohol Sensitive to chemical/smells Aspartame consumption or sensitivity Nose runs while eating Anal itching Fungal/Yeast infections Feel worse in moldy/musty places Page 3 of 6
4 Dark circles under eyes How many bowel movements do you have per day? Per week? Have you ever had parasites? Y N Urinary: Increased frequency. Frequency at night. Chronic Infections. Incontinence How many times a day do you urinate?. Musculoskeletal: Joint Pain. Stiffness in joints. Muscle spasms. Arthritis. Weakness Joint swelling Neurological: Fainting Seizures Paralysis Loss of memory Involuntary movement Loss of balance Speech problems WOMEN S HEALTH Age of your first menstrual period? When was your last menstrual period? How many days do you bleed? How long between your periods (onset to onset)? Do you experience: When: (check boxes) Premenstrually menstruation During Heavy flow? Light flow? Clotting? Bleeding between periods? Cramping? Irritability Blues or depression Bloating &/or water retention Headaches Breast tenderness Cravings Low back pain Are you pregnant? Y N Number of pregnancies Number of births Have you ever used birth control? Y N What type? How long? What type of sanitary product do you use (i.e. pad, tampon, etc)? Please indicate if any of the following applies to you: Vaginal Discharge. Abnormal pap tests. Oily skin Fibrocystic breasts Pain during intercourse. Low libido. Water retention Polycystic ovaries Vaginal Itching. Vaginal dryness. Vaginal Odour. When was your last Pap test? Breast Health: Do you perform monthly self breast exams? Y N When was your last clinical breast exam? Do you have regular mammograms? Y N Have you experienced nipple discharge? Y N When? MEN S HEALTH Please indicate if any of the following applies to you: Hernia Y N Testicular mass and or pain. Y N Do you perform self testicular exams? Y N 4
5 Low sex drive Y N Discharge or sores Y N Impotence or Erectile Dysfunction Y N Difficulty with urination and/or frequent urination Y N Prostate condition. Y N Year of last prostate exam? LIFESTYLE Do you exercise? Y N How & how often? Do you fall asleep easily? Y N Average 6-8 hrs of sleep? Y N Sleep soundly? Y N Wake rested? Y N Do you smoke tobacco? Y N Do you chew tobacco? Y N Do you use drugs? Y N Do you drink alcohol? Y N Do you eat out regularly? Y N How often? CONTEXT OF CARE OVERVIEW Why did you choose to come to this clinic? What do you know about our approach? What three expectations do you have from this visit to our clinic? What long term expectations do you have from working with our clinic? What expectations do you have of me personally as your physician? 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) What behaviors or lifestyle habits do you currently engage in regularly that you believe support your health? (please list) What behaviors or lifestyle habits do you currently engage in regularly that you believe are self destructive lifestyle habits: (please list) 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? Who do you know that will sincerely support you consistently with the beneficial lifestyle changes you will be making? What do you LOVE to do? WHEEL OF HEALTH Page 5 of 6
6 Physical Environment Career Family & Friends Money 100 % 80% Personal Growth Health Example: 90% 70% Fun & Recreation Significant Other/ Romance 60% 100% 80% 60% 50% 50% Wellness is a balance of many factors. Using the circle, shade your level of satisfaction in each area as it relates to you. For example, if you are extremely happy in your career, shade the entire pie shape for career. Do the same for each area, starting from the center point radiating outwards. Thank you for taking the time to fill out these forms! 6
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