Integrative Medicine Intake Form
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- Dustin Gallagher
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1 Integrative Medicine Intake Form Please complete the following form in order to provide us with the background information we require to ensure you receive comprehensive care. It should take minutes. Please completed form to prior to your first appointment. Contact Information: Name Gender Occupation Employer Date of Birth Work Phone # Emergency Contact Home Phone # Emergency Contact # Cell Contact Relationship Home OHIP Number Would you like to receive communication via Appointment reminders and communication from our front desk staff about your appointment Communication from your integrative practitioners about your care Our Monthly newsletter including seminars and special events How did you hear about the? (If another person, please provide name) Care Co-ordination: Medical Doctor Medical Doctor # # Medical Doctor Dentist Dentist # # Dentist Please List any other Medical Providers: Type of Medical Provider Name Phone # _Y
2 Health Priorities / Chief Concerns: List your main heath concerns (or reasons for visiting the clinic) in order of importance Have you received integrative care before? Massage Chiropractic Naturopathic Medicine Counselling Physiotherapy Other: Did another health care practitioner refer you for treatment? Name: Do you currently feel pain or discomfort? Have you had a similar symptom in the past? How was this past symptom treated? Does the Pain Travel? What is the nature of the pain (i.e stabbing, dull, burning, pins and needles, aching, stiff & tight): Does anything aggravate or relieve the pain?: Does the pain wake you from your sleep? Is the pain worse in the morning?: Does the pain get better during the day?: Does your work or daily activities interfere with the pain?: Is there anything else that you think may be important?: Medical History: How would you describe your general state of health? excellent good fair poor Medical conditions: Please indicate any serious illnesses, conditions, or reasons for hospitalizations Medical Condition/ Hospitalization Date of Diagnosis/ Diagnosed by whom Is the condition still present Symptoms
3 Allergies or Food sensitivities: Please indicate any allergies and/or serious food sensitivities Allergy/Sensitivity Severity of reactions Medications/Supplements: Please list all current medications/supplements Medication/Supplement Dose (if known)/ Length of Use Prescribing Physician Condition it is treating Past Medications/Supplements: Please list all past medications/supplements in the last 5 years. Medication/ Supplement Dose (if known)/ Length of Use Prescribing Physician Condition it is treating Have you taken anti-biotics within the last 5 years? Y N Vaccinations: Please indicate which vaccinations you have received. Vaccination against: Age Side Effects / Hospital Admittance Measles, Mumps, Rubella (MMR) Diphtheria, Pertussis, Tetanus (DPT) Haemophilus Influenza B (Hib) Chicken Pox (Varicella Zoster) Rabies Hepatitis A Hepatitis B Tetanus Polio Flu Other:
4 Review of Systems Please list conditions or concerns that involve the following systems: SKIN (eg. eczema, psoriasis, hives, rashes) HEAD (eg. headaches) EYES (eg. itching, pain, infection, corrective lenses) EARS (eg. wax, discharge, hearing impairment) NOSE (eg. sinus problems, pain, nose bleeds) MOUTH (eg. difficult dentition, cavities, loss of taste, problems swallowing) NECK (eg. stiffness, tenderness, hoarseness, tonsillitis, swelling) HEART (eg. rheumatic fever, murmurs, chest pain) LUNGS (eg. cough, asthma, wheezing) GASTROINTESTINAL (eg. vomiting, swallowing, diarrhea, constipation) URINARY (eg. pain, increased frequency, blood) MALE (eg. hernias, pain or masses in scrotum/testes) FEMALE (eg. urgency, menstruation/menarche, discharge, pain or masses in ovaries/uterus MUSCLE AND SKELETON (eg. joint pain, stiffness, weakness, back pain, fractures) NEUROLOGICAL (eg. seizures, paralysis, clumsiness, memory, vision changes, speech problems, sensation alteration) Please indicate where you are feeling discomfort. Provide as much detail as possible.
5 Do you use/have any of the following? Substance Alcohol How often/ How much/ What brand/type Cigarettes Recreations Drugs Aspirin/Tylenol/Advil Laxatives Ant-acids Diet Pills Coffee Black Tea Green Tea Birth control pill Birth control implants Birth control injections Metal implants Mercury Fillings Resin fillings Other How many? How many What was the date of your last physical exam? Have you ever had and abnormal lab test results? Please indicate results: Female: Are you currently or could you be pregnant: Y N How many weeks: Have you ever been pregnant? Y N How many times: How many vaginal births: C-Sections: How old were you when you had your first period: Have your periods been regular: Have you taken/used: The birth control pill/when: The patch/when: An IUD/ when: Depo Provera injections/when: Other: Are you currently: Pre-menopausal Transitioning through menopause Post-menopausal Have you/are you, taking HRT: Y N How long:
6 Family History: Illness Family Member Complications / Severity Allergies Asthma Diabetes Heart Disease Cancer Depression Other mental illness Kidney disease Infertility Post-partum depression High Blood pressure Other Family History Unknown Lifestyle Do you identify as: straight homosexual bi-sexual trans-gendered other: Do you have a strong emotional support network: Y N Who: Have you experienced any major trauma or loss in the past 5 years? Have you experienced any other trauma or loss in your life? How would you currently rate your level of stress at this time? Minimal Average Considerable Unbearable What are the major causes of stress in your life at this time: (check all that apply): financial career personal marriage/relationship health family spiritual other (please elaborate): How does your stress manifest itself: What type of coping mechanism to you employ to manage your stress? What do you do for exercise/movement? (Indicate type, frequency and time of day): Do you have a history of concussion? Y N Date: How many hours per night do you sleep: nap: Do you wake rested in the morning: Y N
7 How old is your mattress? Describe the comfort level of your pillow What is your occupation: Do you enjoy your work: Y N Sometimes How many hours per day do you spend on the following: Driving Watching TV Reading In front of a computer Work When was your last vacation: Do you actively participate in a spiritual discipline (church, synagogue, meditation, etc ) Y N Dietary Habits What time of day do you eat the following: Breakfast: Lunch: Dinner: Snacks: Do you consume the following (circle all that apply and indicate frequency): Fresh Vegetables: Fresh Fruit: Cold-water Fish: Tuna: canned goods: Pop: Milk: Coffee: Water: Juice: Processed Foods: Microwavable meals: Red meat: Cheese: Chocolate: Aspartame: Deli meats: Fast Food: Margarine: Do you crave (circle all that apply): Sugar I Chocolate I Salt I Crunchy foods I Other: Do you have regular bowel movements: Y N Do you have to strain for a bowel movement: Y N Do you regularly have loose stools: Y N Do you associate digestive difficulties with any particular foods: Y N Which foods: How many bowel movements do you have per day? Additional Information If there is any other relevant information pertaining to your health that was not covered in this intake please state it below:
Date of Birth Work Phone # ( ) Home Phone # ( ) Emergency Contact # ( )
Please complete the following form in order to provide us with the background information we require to ensure you receive comprehensive care. It should take 15-20 minutes. Contact Information: Name Occupation
First Name: Middle Initial: Last Name: Address: City: State: ZIP: Today s Date
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Name Date of Birth. City Province Postal Code. Phone # home mobile Phone # (wk) Okay to leave a message re: appointments?
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Child Intake Form. In case of emergency, contact: Relationship: Phone:
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MONTCLAIR HOMEOPATHY LLC Linda Corenthal Robins, M.D. Montclair, NJ 0704 Office 973-746-9888 www.montclairhomeopathy.com PEDIATRIC REGISTRATION FORM Referred by: Name Nickname Birth date Mother s Name
Head to Heal Centre for Naturopathic Medicine & The Bowen Technique
Head to Heal Centre for Naturopathic Medicine & The Bowen Technique CHILDREN S QUESTIONNAIRE (To be completed by parent/guardian) Date: Child s Name: Mother s/guardian s Name: Mother s/guardian s Occupation:
DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
Medical History: Patient: DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N) List the names of prescription
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
Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic th Avenue Surrey BC V4A 2H9 Tel: Fax:
Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic 690 15355 24 th Avenue Surrey BC V4A 2H9 Tel: 604.541.9336 Fax: 604.541.9308 I. Patient Information Thank you for choosing our practice for
Birch Wellness Center
Dr. Kelly Brown drkbrownnd@gmail.com Birch Wellness Center 34 Carlton Street, Winnipeg, Manitoba R3C 1N9 204 505 0325 (f) 204 505 0327 Full Legal Name: (Last, First) / Preferred Name: Date of Birth: Age:
Patient Information. Marital Status (Single, Married, Life Partner, Divorced, Widowed) CHIEF COMPLAINT
Patient Information Name Date Home Address City State Zip Phone E-mail Address Cell Phone: Business Address City State Zip Phone Occupation Place of Birth Date of Birth Age Height Weight Soc. Sec. # Sex
CONSULTATION ADMITTANCE FORM
CONSULTATION ADMITTANCE FORM Last Name: First Name: Address: City Postal Code: Home Phone: Work Phone: Age: Birth date (dd/mm/yr): Sex: M / F Height Weight Occupation: Alberta Health Care #: PLEASE CHECK
Family Naturopathic Clinic Adult Intake and Consent Form
Health History Form (GENERAL) Name Birth-date Date MSP # Blood Type Address City Prov/State Postal Code Phone (home) Phone (work) best time to call Can we leave messages for you here? Y N Email Occupation
HISTORY OF PRESENT ILLNESS A. TELL US ABOUT YOUR PAIN PROBLEM
1 UT Health Austin Comprehensive Pain Management New Patient Questionnaire Thank you for scheduling a visit with the Comprehensive Pain Management Care Team. The responses you provide to these questions
A. Please include any medications (herbal, prescription, or Over-the-counter) and any supplements that you are currently taking.
New Patient Questionnaire Please complete this and bring it with you to your visit. If you have it completed five days or more prior to your visit, please mail or fax it to our office. Most recent treating
We look so forward to seeing you at your first visit! If you have any questions, don t hesitate to call us at (705)
Welcome to StoneTree, and to the first steps on your way to feeling better! Thank you for choosing us as a part of your health care team. Your Forms and Health History Your new patient intake forms are
City: State: Zip: Age: Height: Current weight: Weight 6 months ago: Employer: Work #: Ext:
1 Last Name: First Name: Middle Initial: Address: Apartment #: City: State: Zip: Home #: Cell #: Email: How did you find us? Patient (who) : Doctor (who) : Staff (who) : Date of Birth: / / Gender (circle
Pediatric Intake Form
Patient Name DOB Pediatric Intake Form 1 Pediatric Intake Form Welcome. Our philosophy and approach to medicine is wholistic and seeks to understand all factors that may be affecting your health. This
ADULT INTAKE FORM - NATUROPATH Date:
ADULT INTAKE FORM - NATUROPATH Date: Name Date of Birth Gender (please circle) F M Weight (current) lbs Marital Status Single Married Divorced Partnership Height (inches or cm) Widowed Other Do you have