ADULT CLIENT INFORMATION SHEET Date of Initial Appointment:
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1 Dr. Han Ping Helen Cen, ND ADULT CLIENT INFORMATION SHEET Date of Initial Appointment: Name: Birthday: Address: City: Province: Postal Code: Home Phone: Cell: Work: Appointment Notifications: We will advise you of your upcoming appointments 24 hours in advance. Please circle which is the best way to contact you for notifications: Text Phone Call Electronic Messages: Would you like to receive s including monthly newsletters, promotions, upcoming classes and information from Health Matters? (Please circle one) YES NO How did you hear about us? Facebook Google Referral In-Store Other Sex: Date of Birth: Age: Current weight: Height: Who is filling out this form if not self? (Name and relationship): Occupation: Marital Status: Number of Children: Pregnant: Y N If yes, how many weeks: Breastfeeding: Y N Emergency Contact Name: Phone Number: Relationship: Name of Medical Doctor: Phone Number: Have you received naturopathic care previously? Y N If yes, when? Name of practitioner: For what reason? Health Concerns What are your main health concerns in order of importance to you?
2 Vitamins and Supplements Please list all vitamin/mineral/herbal supplements you are currently taking: **Please bring in all supplements info (or photo) to initial visit** Supplement (Including Brand) Dosage When did you begin supplement? Medication Please list all prescription and non-prescription medication you are currently taking: **Please bring in all medications to initial visit** Please list all prescription medications you have taken in the past for longer than 6 months. Indicate how long you have taken each for: Family History Is there a history of any of the following in your family? Please check and then list relationship of family member beside the condition. Alcoholism Cataracts Kidney Disease Allergies Celiac Learning Disability Arteriosclerosis Colitis Mental Disease Arthritis Depression Multiple Sclerosis Asthma Diabetes Schizophrenia Bed Wetting Epilepsy Tuberculosis Candida Albicans Heart Disease Yeast Infections Cancer Hyperactivity Medical History Please list any injuries and/or major surgery you have had and when they occurred. Please list any major illnesses or diseases that you have or have had.
3 Vaccinations (please check) DPT (Diphtheria, Pertussis, Tetanus) Flu Shot MMR (Measles, Mumps, Rubella) Hepatitis A Hepatitis B Chicken Pox Polio Other Did you experience any symptoms from them? If yes, please explain. Diet Non Vegetarian Vegetarian Vegan For How Long? How many cups/bottles/glasses do you drink, on average, per day? Coffee Milk 2% Fruit juice Tea Skim milk Soft drinks (diet) Water Beer Soft drinks (regular) Herbal tea Wine Vegetable juice Milk 1% Liquor Other All allergies/intolerances/sensitivities: Review of Symptoms Please check any of the following that apply to you or write P beside the box if you have experienced any in the past. General Fatigue Night sweats Sleep problems Change in appetite Allergies Hours of sleep per night Change in thirst Heat or cold intolerance Sudden drop in energy (time?) Bleed or bruise easily Cancer Skin Rashes/hives/itching Hair changes (colour/quantity) Skin ulcers/skin cancer Eczema/psoriasis Changes in skin color Warts Nail changes (strength/shape) Excess dryness/moistness Recent moles Acne/boils Head, eyes, ears, nose, and throat Headache Blurred/double vision Ringing in the ears Problems with jaw joint/tmj Use of glasses Poor hearing Head injury Date of last eye exam Sinus issues Migraines Cataract Frequent colds Dizziness Floaters/blind spot Mercury dental fillings Light-headedness Earache/infection Cold sore/ canker sore Eye pain Excess ear wax Swollen glands Heart and circulation High blood pressure Irregular heartbeat Varicose veins High cholesterol Palpitation/fluttering Blood clots Heart disease Chest pain Cold hands and feet
4 Neurological Fainting/loss of consciousness History of concussion Twitching Seizures Loss of sensation Tremors Speech problems/slurring Numbness/tingling Memory problems Endocrine Thyroid problems Weight gain Hormone replacement therapy Diabetes Weight loss Musculoskeletal Joint pain / stiffness Muscle weakness Osteoporosis Sciatica Muscle spasm / cramp Urinary Pain / burning while urinating Urinary tract infections Kidney problems Inability to hold urine Blood in urine Kidney stones/infection Urgency/hesitation Sexual Health Sexually active Sexually transmitted infection Contraception use Please mark an X to indicate areas where you feel pain, swelling or discomfort, or areas of your skin that have changed in color or texture (e.g. moles, rashes, etc.). Describe what you feel or observe in your own words. Write anywhere in this area. Thank you for taking the time to complete this form to your best knowledge.
5 Informed Consent Please note that this form must be signed prior to your first appointment. Naturopathic medicine is the treatment and prevention of diseases by natural means. Naturopathic Doctors assess the whole person, taking into consideration physical, mental, emotional and spiritual aspects of the individual. Gentle, noninvasive techniques are generally used in order to stimulate the body s inherent healing capacity. Your clinician, Han Ping Helen Cen ND, will take a thorough case history, perform a physical examination, which can include a breast exam, and take blood and urine samples. If your case requires, the physical may include more specific examinations such as gynecological, rectal, prostate or genital exams. There are some slight potential risks associated with treatment by naturopathic medicine. These include but are not limited to: Homeopathic remedies may occasionally result in the aggravation of pre-existing symptoms. When this occurs the duration is usually short. Some patients experience allergic reactions to certain supplements and herbs. Please advise your clinician of any allergies you may have. Pain, bruising or injury from venipuncture or acupuncture or parental therapy. It is very important that you inform your Naturopathic Doctor immediately of any disease process from which you are suffering and any medications/over the counter drugs that you are currently taking. Please advise your Naturopathic Doctor immediately if you are pregnant, suspect you are pregnant or if you are breast-feeding. As a patient, you will receive information about your diagnosis and/or treatment, alternative courses of action, the material effects, costs, expected benefits, risks, side effects and in each case the consequences of not having the diagnosis and/or treatment acted upon. The Naturopathic Doctor is trained to handle emergencies should the need arise. I understand: That naturopathic treatments and conventional treatments are not mutually exclusive and therefore I am free to seek or continue medical care from a qualified physician. The clinic does not guarantee treatment results. That my Naturopathic Doctor will explain to me the exact nature of any treatment provided and will answer any questions I may have. I am free to withdraw my consent and to discontinue treatment at any time. CANCELLATION POLICY Please note a no show appointment is a loss of income for our practitioners and delays our work. When you must cancel, please give us at least 24 hours notice. We are rarely able to fill a cancelled session unless we know at least 24 hours in advance. If you are unable to provide at least 24 hours notice when you cancel, a $25 cancellation fee will be applied. Patient or Lawful Representative Signature Date signed Full Name Printed
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Elements of Health 55 S. Main Street, Driggs, ID 83422 (208) 920-0312 Name: (first) (middle) (last) Date: / / Address: Phone: / street address city zipcode home / cell Date of Birth: / / Age: Gender: M/F
Naturopathic Intake Form
Naturopathic Intake Form Date: Name: Date of Birth: _ Are you related to any other patients? Sex:! M! F Marital Status:! Single! Married! Divorced! Widowed Profession: Cultural Heritage: Place of Birth:
Adult Intake Form. In case of emergency, contact: Relationship: Phone:
Personal Information Date: Adult Intake Form Name: Sex: M F Age: Birth Date: Address: City: Province Postal code: Telephone (Home): (Work): (Cell): Email: Preferred contact for appointment reminders: email
Headache Follow-up Visit Form
!1 Headache Follow-up Visit Form We will be unable to see you unless this form is completely filled out. We appreciate your thoroughness. Name DOB Age Today s Date Referring doctor: Primary doctor: Neurologist:
NEW PATIENT QUESTIONNAIRE
NEW PATIENT QUESTIONNAIRE PLEASE PRINT Full name: Age: Preferred Contact number: Email address: Why are you here today? To establish primary care Annual exam Consultation from another doctor If consultation,
Sandra Cross RNCP, RBIE. First Name: Last Name: Age: Birth Date: Sex: Male Female
Sandra Cross RNCP, RBIE ADULT INTAKE FORM First Name: Last Name: Age: Birth Date: Sex: Male Female Street Address: City: Province: Postal Code: Phone: (Home) (Work) (Cell) May we leave a message? Yes No
New Patient Intake Form
501 Islington Street, Suite 2B Portsmouth, NH 03801 P: 603-610-8882 F: 603-463-0943 New Patient Intake Form Personal Information Today s Date Name Age DOB: Phone: H ( ) W ( ) Cell ( ) Preferred Home Work
CONSULTATION ADMITTANCE FORM
CONSULTATION ADMITTANCE FORM Last Name: _ First Name: Sex: M / F Address: City Postal Code: Home Phone: Work Phone: Cell Phone: Cell Phone Provider: E-mail: Occupation: Marital Status: No. of children:
Patient s Name: Birthdate: (dd/mm/yyyy) Sex: Mailing Address: Phone Number: Family Doctor or Paediatrician. How did you hear about the clinic?
Pediatric Intake Form Thank you for taking the time to fill out this form. This information is very important in order to best assess your child s needs. Patient s Name: Birthdate: (dd/mm/yyyy) Mother`s
2. Approx. Date of Onset: 3. Approx. Date of Onset:
Healthy Balance Lisa A. Dulac, L.Ac. Acupuncture Patient Intake Form Present Health Concerns: Please list your most important health concerns in order of their significance. 1. Approx. Date of Onset: 2.
Dear. Your appointment information is as follows: Date: Time:
MacDonald Naturopathic Medical Clinic Dr. Crista MacDonald-Werby, BHSc., ND Doctor of Naturopathic Medicine 29 Wellington Street North, Woodstock, Ontario N4S 6P4 Tel: (519) 539-7000 Dear Thank you for