Carolyn Mercer, B.Sc., N.D Orleans Blvd, Unit 6 Ottawa, ON K1C 7E2 (613)
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1 Carolyn Mercer, B.Sc., N.D Orleans Blvd, Unit 6 Ottawa, ON K1C 7E2 (613) PERSONAL INFORMATION Name: Age: Date of Birth: Address: Office Phone: Home Phone: Marital Status: S M D W Sep Name of Spouse: Dependants: How did you find out about the clinic? Emergency Contact: Relation: Phone Number: Address: Health Care Resources: Medical Doctor: Office: Fax: Other Health Care Practitioner: Office: Fax: Other Health Care Practitioner: Office: Fax: 1.Main Health Concern: What is your chief concern? 1
2 Who diagnosed this condition? When? Current Treatments or Regimes Treatment or Regime Doctor or Therapist Last Visit How long has it been since you were totally well? 2. Medical History Prenatal Influences (eg: alcohol, cigarettes, drugs, stress) Breast fed: mos. Describe your health as an infant/child? Have you been vaccinated: Yes No Have you ever had a severe reaction to a vaccination? If yes, explain: Did you have any specific health concerns as a teenager (eg: acne, weight, mono, other)? Adult Illness Age Were you hospitalized? Do you have any history of previous surgeries or accidents? Were there any complications? Was other treatment required? 2
3 List all prescribed medications presently being taken: Drug Name Dosage Frequency How Long List any over the counter medications you take ( Tylenol, Tums, Cold/Flu Remedies) Indicate how often you take them? How many courses of antibiotics have you been on in the past 10 years? Have you ever had a bad reaction to an antibiotic? Have you ever had a nervous breakdown? If yes, what type of treatment did you receive? 3. Family History Relative Age Ailments Mother Father Brothers Sister Children Maternal grandmother Maternal grandfather Paternal grandmother Paternal grandfather 4. Lifestyle Diet: normal, junk food, vegetarian, other What is an average days food intake. Include beverages? Breakfast Lunch Dinner Snacks Do you eat quickly? Standing up? On the run? 3
4 At restaurants? If so, which ones? List all food supplements you are currently taking and the total dosage? Exercise: Type: Quantity? Drugs: Do you smoke? If so, for how long? How many per day? Does anyone else smoke in your household or workplace? How many alcoholics do you have per week? Sleep: What are your regular sleeping hours? From to Do you wake feeling refreshed? Relaxation: What do you do to relax? 4. Psychosocial History List any important life experiences in chronological order, especially traumatic events. Age Event Comment Briefly outline a typical week day. What do you do from waking to sleeping? Age Activity Time Activity Who are the most significant others in your life and what are the challenges in each relationship? What is your view of the present and your outlook for the future? 4
5 How do you feel about yourself? Do you have a preference for the type of treatment used? Do you have supportive home environment for making these changes? Religion/Spiritual Path? General Height Weight Changes in weight Energy: hi med low Fatigue Skin Rash Lumps Itching Dryness Colour Change Change in Hair Change in Nails Eczema Blood Abnormal blood test Bleed/Bruise easily Anemia Allergies Head Headache Head Injury Forcep Birth Eyes Poor Vision Glasses/Contacts Sensitive to Light Last Eye Exam Pain Redness Discharge Excess tearing Double Vision Glaucoma Cataracts Infections Ears Poor hearing Ringing in ears Dizziness Earaches Infection Discharge Excess ear wax Nose/Sinuses Frequent Colds Nasal Stuffiness Hay Fever Nosebleeds Mouth/Throat Cavities/Root Canals Poor gums Sore Tongue Cold/Canker Sores Last Dental Exam Coated Tongue Hoarseness Frequent Sore Throat Bitter Taste in Mouth Lymph Nodes Neck/Underarms/Groin Lumps Pain Breasts Lumps Pain Nipple Discharge Self examination Lungs Cough Sputum Wheezing Shortness of breath Last Chest x-ray Difficult breathing at night Heart Heart Problems High Blood Pressure Rheumatic Fever Swollen Ankles Chest Pain Palpitations Last ECG/Other tests Cholesterol hi/low Heart Murmurs Urinary Urinations per day Urination at night Pain Blood in Urine Urgency Kidney Trouble Incontinence Infections Stones Dribbling Musculoskeletal Joint Pains Stiffness Arthritis Bad Posture Gout Backache Muscle pain/cramps Circulation Pain in calves after exercise Leg cramps Varicose Veins Cold extremities Thrombophlebitis Digestion Trouble swallowing Heart burn Nausea Appetite up and down Vomiting w/blood Indigestion Bowel movements/day Rectal Bleeding Change in bowel movements pale black stools w/ undigested food constipation diarrhea abdominal pain difficulty skipping a meal food intolerances food cravings excess belching bloating passing gas haemorrhoids jaundice liver or gallbladder trouble hepatitis Nervous System Fainting Blackouts Paralysis Local weakness Numbness Tingling Tremors Memory Problems Female Age at first period Length of cycle Duration of Periods Cycle Length Regular? Last period Amount of bleeding b/w periods after intercourse Painful Periods Age of Menopause Symptoms Post Menopausal Bleeding Discharge Itching Infections Treatments Last pap smear # of pregnancies # of deliveries # of abortions complications of pregnancy birth control libido sexual difficulties Male discharge from penis sores on penis hernias testicular pains venereal disease treatment masses prostate problems libido sexual difficulties Mind Nervousness Tension Mood swings Depression Lack of concentration Fuzziness Emotions Excess anger/ sadness/ Frustration/ mania/ Difficulty feeling or Expressing emotions 5
6 Sinus Trouble Immune Allergies HIV Positive Endocrine Thyroid trouble Excessive sweating Diabetes Excess hunger/thirst, urination Stroke 6
7 Carolyn Mercer, B.Sc., N.D Orleans Blvd, Ottawa, ON K1C 7E2 Statement of Acknowledgement and Release: Naturopathy uses non-invasive methods for the assessment of bodily dysfunctions, and natural therapeutics for their correction. Each person seeking care from Carolyn Mercer should understand that she is a specialist in Naturopathy and is not a Medical Doctor (MD) and that you are accepting or rejecting services based on your own free will and choice. If standard medical diagnosis or treatment is required it must be obtained from a licensed Medical Doctor. Each patient or their legal guardian must read and sign this document before any treatment will be rendered. Your signature acknowledges the following: 1. You have read the foregoing information and you understand that responsibility for your own health is your own and you understand that improving lifestyle can be as important as remedies and treatment. 2. You understand that Carolyn Mercer is a Naturopathic Doctor and is not a Medical Doctor and may employ alternative means of achieving a diagnosis. 3. You understand treatment and/or referral to other health care practitioners is based upon the assessment of conditions revealed through your personal history and interview, physical exam and lab testing. 4. The decision to discontinue prescription drugs or any other prescribed treatment is your sole responsibility. If you forego standard medical treatment in favour of natural healing, you assume responsibility for any potential risks that may be entailed. 5. You are not an agent of any private or local, county, provincial or federal agency attempting to gather information without stating your intentions. 6. You understand that you accept all responsibility for fees incurred during care and treatment and the fees for services rendered are to be paid at the end of each visit. 7. You understand that naturopathic visits are not covered by the provincial governments but are covered under many extended health insurance plans and may also be tax deductible. I, (Print name of patient or legal guardian) have read, understood and acknowledge the above statements and give my consent to be treated by Carolyn Mercer. I am the legal guardian of. (Print name if applicable.) I also understand that 24 hours notice must be given for cancellation or changing of an appointment time or the full fee will be charged. (Sign Here) I understand that my health records may be used in research providing my name is not revealed. At all other times, my health records will be held in the strictest confidence. (Initial Here) Date: Signature: Witness: 7
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Date: Date of Birth: Age: Sex: Male Female Address: City: State: Zip: Telephone: Email: PREFFERED PHARMACY NAME & LOCATION: PRIMARY PHYSICIAN: SPECIALISTS: INSURANCE GoPrivateMD will not bill your insurance.
Eastern Body Therapy
2310 Eastern Body Therapy 6th Avenue San Diego, CA 92101 (619)772-4002 Personal Information Name Date of injury/illness Address: Apt. City State Zip Home phone: ( ) Work Phone: ( ) E-mail: Social Security
Name Age Date. Address Phone. Name of Physician. Address Street Address City State Zip Code
Name Age Date Address Phone What is the reason for your visit today? Where have you been receiving your medical care? Name of Physician Address Street Address City State Zip Code PAST MEDICAL HISTORY:
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
Name: Date: Referring Provider: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary).
Name: Date: Referring Provider: Age: D.O.B. Race/ ethnicity: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary). We are interested in learning
PATIENT INTAKE SHEET 2016
PATIENT INTAKE SHEET 2016 Patient Name: Last First Middle D.O.B.: Sex: M F Year Month Day Address: Street Address City May we leave a detailed message? Postal Code Phone : Residence Yes [ ] No [ ] Work
Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY
PATIENT QUESTIONNAIRE / ASSESSMENT Endocrinology Form Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY Date Phone (H) (W) (C) Age Male Female Marital
Naturopathic Intake Form PERSONAL MEDICAL HISTORY
List any surgeries, hospitalizations, imaging (CT, MRI, EEG, EKG, etc.) Date MM/YY ALLERGIES Do you have any allergies to medications? [ ] Yes [ ] No If yes, list medication and reaction Do you have any
UCCM ANISHNAABE POLICE SERVICE EMPLOYMENT VISION REPORT
APPLICANT NAME: UCCM ANISHNAABE POLICE SERVICE EMPLOYMENT VISION REPORT REACTION ACCOM. LIGHT PUPILS EQUAL UNEQUAL FUNDI FIELDS OF VISION COLOUR (TEST USED) WITHOUT GLASSES NEAR FAR WITH GLASSES RIGHT
stoneburner acupuncture
STONEBURNER ACUPUNCTURE, LLC Erin K. Stoneburner, LAc, MAcOM 1135 SE Salmon St, Suite 211 503.784.1660 stoneburner@gmail.com Date: Name: (First) (Middle) (Last) DOB: _ Age: Sex: Address: City/State: ZIP:
Dr. Michelle Cruickshank
CHIROPRACTIC INTAKE FORM A Multidisciplinary approach to medicine is holistic and seeks to understand all factors that may be affecting your health. Please answer the following questions to the best of
Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire
Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire First Name: M.I. Last Name: Date of Birth: Phone: Marital Status: Married Divorced Separated Widowed Single Work Status: Employed
Marcelo Garzon HOM.DSHomMed.Bsc. (Please be certain that all in take forms are completed and returned on time)
Marcelo Garzon HOM.DSHomMed.Bsc. www.sagehomeopathy.ca (Please be certain that all in take forms are completed and returned on time) NAME: Personal Health History DATE: OHIP # D.O.B : AGE: PHONE: MAY WE
Healthworks Nutrition Centre. Naturopathic Medical Questionnaire. Name Date of First Visit. Address. Province Postal Code. Telephone # (home) (work)
Healthworks Nutrition Centre Naturopathic Medical Questionnaire PERSONAL INFORMATION Name Date of First Visit Blood type # of Children Address City Province Postal Code Telephone # (home) (work) E-mail
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please