ARGYLE NATURAL HEALTH CENTRE NATUROPATHIC INTAKE FORM. Full Name: (First) (Middle) (Last)
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1 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: City: Postal Code: Tel (home): Tel (work): Tel (cell): Occupation/Employer: Referred By: Emergency Contact - Name: _ Tel: Health card number: Medical Doctor(s): address: ( ADDRESSES ARE USED FOR CONFIRMATION OF APPOINTMENTS AND APPOINTMENT REMINDERS) What are your major health concern? Please list them in order of importance: Circle any of the following conditions you have or may have had: abcess diabetes hepatitis multiple sclerosis rheumatic fever tuberculosis abortion emphysema HIV mumps rubella/german measles typhoid fever alcoholism epilepsy influenza parasites scarlet fever venereal warts anemia frequent colds kidney disease peritonitis sexual abuse warts arthritis gallstones leukemia pelvic inflam. dis. skin diseases whooping cough asthma genital herpes low/high blood pr. pleurisy sinusitis worms cancer gonorrhea malaria pneumonia stroke yellow fever chicken pox gout measles PMS strep throat others: cold sores hayfever miscarriages prostatitis syphilis depression heart disease mononucleosis psychiatric illness tonsilitis Have any of your family members suffered from any of the conditions listed above? If so, please indicate their condition(s), their relation to you and their age at the time of their illness or death (e.g. high blood pressure - mother - 76)
2 For each of the following family members, please indicate present age and health status, or age at the time of death and cause of death: Mother: Father: Mother s mother: Mother s father: Father s mother: Father s father: Children: Sister(s)/brother(s): What immunizations have you had, and did you react badly to any of them? Immunizations Reaction, if any Measles, Mumps, Rubella (MMR) Smallpox Diptheria, Pertussis, Tetanus (DPT) Hepatitis Polio Others Others What surgeries or major injuries have you had? Have you ever been hospitalized? If so, why and when? What medications, if any, are you currently on? What natural supplements (vitamins, minerals, herbs,...) are you currently on? Do you have any known allergies or intolerances? If so, what are they? Have you ever seen a naturopath or other complementary alternative health professional? If so, what were they? Have you ever suffered any serious trauma in your life that you feel is still affecting you?
3 What is a typical day s diet for you? Breakfast: Lunch: Supper: Snacks: Drinks: Indicate if any of the statements below apply to you (please elaborate): Diet often Eat out often No regular exercise Consume caffeine Exposed to chemicals or environmental hazards Exposed to tobacco Consume alcohol Use recreational drugs What is your: Weight now? Minimum adult weight? Maximum weight? Ideal weight? Height? How much leisure time do you usually have? What are your typical leisure activities? Do you enjoy your job/school? Why or why not? Do you enjoy your relationships with your family and friends? Why or why not? What is your general outlook on life? How committed are you to making changes in your life in order to improve your health? Thank you for filling this out. The information you provide will assist in providing you with quality naturopathic health care. The Naturopathic Physician's primary purpose is to prevent disease, to promote health, and to restore, maintain and optimize health and well-being through individualized patient care and public education
4 ARGYLE NATURAL HEALTH CENTRE your natural choice for health care 3643 Sherwood Drive, Regina SK S4R 4A7 Tel: (306) Fax (306) Dr. Katherine Cheah, N.D. Dr. Kathleen Fyffe, N.D. I, the undersigned, hereby give my consent to naturopathic care and treatment from the Naturopathic Physician. Naturopathic care and treatment may include, but are not limited to, a physical examination, naturopathic diagnosis, nutritional and dietary counselling, botanical medicine, homeopathy, acupuncture, and lifestyle counselling. I understand that I am entitled to a full description and explanation of any procedure before it is preformed, and that I have the right to refuse treatment should I choose to do so. I have read and understood the above. _ Patient name (please print) Patient signature Date Witness signature
5 Argyle Natural Health Centre Naturopathic FEE SCHEDULE I understand that the fees of the Argyle Natural Health Centre are as follows: VISIT Initial Visit (approximately 2 hours) Follow up visit (approximately 1 hour) Initial acupuncture visit Dr. Fyffe (approximately 1 hour) Follow up acupuncture visit Dr. Fyffe (approximately 30 mins) FEE $ GST $ GST $ GST $ GST The patient will be made aware of any additional costs for other procedures/test. Please note that there is a 24-hour cancellation policy. If 24 hours notice is not given, a $25.00 missed appointment fee will be charged. store. I acknowledge that I may purchase products/supplements prescribed from the N.D. or any health food I, the undersigned do acknowledge that I have been informed of and understand the recommended therapeutic procedure(s)/treatments and have discussed these to my satisfaction. I further acknowledge and confirm that I have been informed of and understand the financial costs, expected benefits, potential risks and side effects, the likely consequences of not having/following the procedures/treatment and what alternative course(s) of action are available to me. I do hereby voluntarily give my informed consent for the recommended therapeutic procedures/treatments as prescribed by the N.D. and for any future modifications of the procedures/treatments. I also understand that I may change the status of my voluntary consent at any time. I intend this consent to apply to all my present and future naturopathic care. SIGNATURE OF PATIENT DATE NAME OF PATIENT PRINTED DOCTOR S SIGNATURE
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)
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NATUROPATHIC PEDIATRIC INTAKE FORM (Birth to 12 years) PERSONAL INFORMATION: Child s Given Name(s): Last Name: Date of Birth (mm/dd/yy): / / Age: Gender: MALE / FEMALE Current Height/Length: Current Weight:
Instructions for Attorneys on completing the Patient Questionnaire
Instructions for Attorneys on completing the Patient Questionnaire (please remove this cover page before providing to the questionnaire to the patient) In order to minimize the amount of time that is spent
Please Read First. Dear Parent,
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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
Washington & Jefferson College Report of Medical History
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Hamilton Back Clinic
Hamilton Back Clinic Intake Form Name: City: Address: Postal Code: Phone: Sex: M F Date of Birth: Month/Day/Year E mail: Emergency Contact: Name/Phone: Name of Family Physician (MD): Employer: Employer
Last First MI. Full Mailing Address:
BridgeMill Family Healthcare, LLC Date Patient Information Name: Full Mailing Address: Last First MI Phone# (Mobile) (Home) (Work) Email Address Date of Birth: Sex: Male Female SS#: Marital Status: Single
Dr. Michelle Mackay Patel, ND
NATUROPATHIC PEDIATRIC INTAKE FORM (Birth to 12 years) PERSONAL INFORMATION: Child s Given Name(s): Last Name: Date of Birth (mm/dd/yy): / / Age: Gender: MALE / FEMALE Current Height/Length: Current Weight:
PATIENT INFORMATION FORM (WOMEN ONLY)
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Naturopathic Family Physician
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
Patient Information. Name: Last First MI. Address: Street City State Zip
Date: WELCOME TO: Name: Address: Patient Information Last First MI Street City State Zip Phone # : (Mobile) (Home) (Work) Can we leave a voicemail or text message? Yes No Email: Date of Birth: Gender:
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
LAKES INTERNAL MEDICINE
LAKES INTERNAL MEDICINE HEALTH HISTORY QUESTIONNAIRE Please print this and complete and bring to your initial appointment. Today's Date Last Name First Name Middle Initial Date of Birth Male Female Education