Naturopathic & Acupuncture Intake Form (Age 14+)
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1 Dr. Katie Thomson Aitken BAS, ND Dr. Alaina Gair, B.Sc., ND 86 Norfolk St., Guelph Contact Information Naturopathic & Acupuncture Intake Form (Age 14+) Name: Gender: Age: Birth Date (dd/mm/yy): Address: City: Postal Code: Phone Home: ( ) Work: ( ) Ext.: Cell: ( ) Okay to leave a message? No / Yes (which number) May we you regarding appointments and information that may be useful to you? Y / N Occupation: Employer: How did you find us? Emergency contact: Relationship: Phone: ( ) Family Physician: Phone: ( ) Fax: ( ) Address: Date of last visit: Blood work done? Findings of concern? Do you receive an annual physical exam? N / Y, from? Specialist Physician(s) and city: Health History What is your MAIN reason for coming in today? 1. Date of Onset: Please list in order of importance any other health concerns that are troubling you: 2. Date of Onset: 3. Date of Onset: 4. Date of Onset: 5. Date of Onset:
2 Medical History What is your current level of energy from 1 to 10 (10 being the best you have ever felt)? Your height: Weight (approx.): Hospitalizations; surgeries; major injuries (please include dates): Are you working or have you worked with a professional counselor, psychologist, social worker, energy healer, pastor or other therapist? N / Y, with: Which over the counter, prescription and/or natural health products do you use? Taking CURRENTLY: Dose: Reason for Use: Dates of Use: Family History Relative: Age if Living: Health Conditions: Age at Death: Cause of Death: Mother Father Sister(s) Brother(s) Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather
3 Other blood relatives with notable health history (e.g. cancer, heart disease, stroke, mental illness, etc.) Relative: Age if Living: Health Conditions: Age at Death: Cause of Death: Please indicate which of the following conditions you have NOW or have had in the PAST: Condition Now Past Condition Now Past Condition Now Past Condition Now Past Allergies Strep Throat Tonsillitis Poor Memory Anemia Measles Whooping Cough Ringing in ears Asthma Mumps Canker sores Balance problems Arthritis Rubella Herpes Speech problems Eczema Chicken Pox Gout Hepatitis Ear Diphtheria Gall Stones Jaundice Infections Psoriasis Scarlet Fever Kidney Epilepsy Stones Hay fever Rheumatic Fainting Diabetes Fever Sinusitis Small Pox Addiction Alcoholism Acne Polio Thyroid problem High blood pressure Pneumonia Yeast Cancer Stroke infections Bronchitis Gas/bloating Migraine Heart disease Tuberculosis Hemorrhoids Headaches Heart attack Malaria Rectal bleeding Infertility Varicose veins Mono Parasites Venereal Gonorrhea disease Warts Broken bones Numbness/ Syphilis tingling Miscarriage Blackouts Visual problems Cold hands/feet Depression Anxiety Physical abuse Emotional abuse Child abuse Sexual abuse Rape Other:
4 Is there any condition or event in your life from which you feel you have been never well since? Marital Status: Number of children: Any other questions or concerns you would like me to be aware of? Thank you, Dr. Katie Thomson Aitken BAS, ND Dr. Alaina Gair B.Sc., ND
5 INFORMED CONSENT TO TREATMENT Please note that this form must be signed in our office PRIOR to the rendering of any treatment or service. At any time during the course of your naturopathic care you may discuss with your Naturopathic Doctor (ND) any questions or concerns that you may have regarding your treatment. Naturopathic medicine is the treatment and prevention of diseases by natural means. Naturopathic Doctors are regulated primary care providers who assess the whole person, taking into consideration physical, mental, emotional and spiritual aspects of the individual. The gentlest and most non-invasive techniques available are generally used in order to stimulate the body s inherent healing capacity and achieve health care goals. Your practitioner will take a thorough case history, perform a relevant physical examination and may order blood or urine testing. If required, the physical exam may include more specific examinations such as gynecological, breast, rectal or genital exam. It is very important to inform your Naturopathic Doctor immediately of any illness from which you or your child are/is suffering and any medications or over-the-counter drugs that you or your child are/is taking. As a patient, or parent of your child who is a patient, you will receive information about diagnosis and/or treatment, alternative courses of action, expected benefits, risks, side effects, costs and the consequences of not having the diagnosis and/or treatment acted upon. There are some slight health 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 and temporary. Some individuals may experience allergic reactions to supplements and herbs. Please advise your ND of any known or suspected allergies. Acupuncture treatment may be associated with pain, bruising around the insertion site; fainting; or puncturing of an organ with acupuncture needles. Your ND is trained to handle emergencies should the need arise. I, (print name) confirm that I have read, understood and agree: That treatment results cannot be guaranteed That I am free to withdraw my consent in full or in part, and to discontinue treatment at any time. That my Naturopathic Doctor will explain to me the exact nature of any treatment provided and will answer any questions I may have. That I have read and understood the Fee Schedule and Cancellation Policy and I agree to take responsibility for the fees incurred in treatment. Patient Signature Date
6 PRIVACY POLICY Privacy of personal information is important at Norfolk Chiropractic Wellness Centre (hereafter: the clinic ). In providing you with quality Naturopathic Care, we are committed to the responsible collection, use and disclosure of your personal information in accordance with current regulations (Personal Health Information Protection act (PHIPA), Ontario 2004). Your personal information will be collected and used for the following purposes: To assess your health concerns To provide health care To advise you of treatment options To establish and maintain contact with you To send you newsletters and other information mailings To remind you of upcoming appointments To communicate with other treating healthcare providers To allow us to efficiently follow-up for treatment, care and billing To complete claims for insurance purposes To invoice for goods and services To process credit card payments To collect unpaid accounts Disclosure: to comply with all regulatory and legal requirements including court orders, statutory requirements to advise authorities of child abuse, reportable diseases and individuals who may be an imminent threat to harm themselves or others To use for educational and research purposes (this includes case summaries, photographs, lab results and other pertinent medical information) Your identity will be protected at all times and, where required, identifying information will be altered to protect your privacy in all the above instances. In the event that your file with us becomes inactive, your personal information will be retained securely for a period of 10 years after your last visit, at which time it will be destroyed. By signing this Consent Form, you have agreed that you have given your consent to the collection, use and/or disclosure of your personal information as outlined above. CONSENT TO COLLECTION AND USE OF PERSONAL INFORMATION: I, (print name), have reviewed the above information and agree that my practitioner and the clinic can collect, use and disclose my personal information for the purposes outlined in this privacy policy, as described above. Patient Signature Date
Sandra Cross RNCP, RBIE. First Name: Last Name: Age: Birth Date: Sex: Male Female
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PEDIATRIC Patient Intake Form
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Child Intake Form. In case of emergency, contact: Relationship: Phone:
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Acupuncture Intake Form
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Patient Intake Form LEGAL NAME: LAST FIRST MI I PREFER TO BE ADDRESSED AS BIRTHDATE: AGE: SEX: F ADDRESS: CITY: STATE: ZIP: HOME PHONE: WORK: CELL:
Patient Intake Form LEGAL NAME: LAST FIRST MI I PREFER TO BE ADDRESSED AS BIRTHDATE: AGE: SEX: F M ALLERGIES TO MEDICATIONS: ADDRESS: CITY: STATE: ZIP: HOME PHONE: WORK: CELL: MAY WE LEAVE A MESSAGE? YES
Adult Intake Form Personal Information
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NEW PATIENT INFORMATION *All information provided is kept in strict confidence
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Dr. Anita Kieswetter BSc, ND Waterloo Naturopathic Clinic Welcome to Waterloo Naturopathic Clinic and the office of Dr. Anita Kieswetter BSc, ND. Congratulations on choosing naturopathic medicine as part
New Patient Paperwork
New Patient Paperwork NAME: Last: First: MI: Nickname: ADDRESS: Street: City: State: Zip: DOB: Male Female SSN#: - - Home: ( ) Work: ( ) Mobile: ( ) Email: If applicable, Spouse s Name: Emergency Contact
Intake Form: Personal History
Intake Form: Personal History Name: Date: Age Birth date Sex Address City State Zip Phone (home) (work)_ (cell) E-mail Occupation Full-time/Part-time Retired Employed by Education In your opinion, what
MacKay Chiropractic, LTD., 7450 W. Cheyenne Ave. #114 Las Vegas, NV (702)
Personal History Date Patient # Name: Address: City: State: Postal Code: Birth date: Age: Sex: M F Home Phone: _ Cell Phone: Social Security #: Type of Work Email (for appt/e-news letter): Business/Employer:
Dr. Brett A. Morgan PATIENT INFORMATION TRUE HEALTH Chiropractic Physician Applied Kinesiologist So. Charleston, WV PERSONAL INFORMATION
Page1 PERSONAL INFORMATION Last Name First Nickname Middlle Initial Prefix Generation Sex DOB SSN Marital Status Height Weight Address City State Zip Phone (Home) (Work) (Cell) Email Occupation Employer
Please be sure to check with your insurance company to make sure that Dr. Kohli is covered under your plan.
Dear You are scheduled for an appointment with Dr. Manoj Kohli at Christie Clinic in the Department of Rheumatology on at. Please check in on the first floor. The office is located on the 2 nd floor of
Patient History Form
Patient Personal Information Name: Date: Age: Occupation: Employer's name: Briefly describe your daily activities at work: Sex: male female Marital Status: single married divorced widowed Spouse's name:
Welcome to Frisco Spinal Rehabilitation. Personal History
Welcome to Frisco Spinal Rehabilitation Personal History Name: Address: City: State: Zip Code: Home Phone: DOB: Age: Sex: M F Cell Phone: E-mail Address: Social Security #: Driver s License Number: Check
Chiropractic Case History/Patient Information
Chiropractic Case History/Patient Information 1 Date: Patient # Doctor: Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Date: Race: Marital:
Peterson Physical Therapy
Peterson Physical Therapy Registration Form Last Name: First Name: Date: Name of parent/guardian (if patient is a minor) Mailing Address: City/State/Zip: Date of Birth: Home Phone: Email: Cell Phone: Cell
Dr. Stephanie Liebrecht, BSc., ND Phone: Saskatoon Wellness Centre Fax: Lorne Ave., Saskatoon, SK S7H 1Y4
Dr. Stephanie Liebrecht, BSc., ND Phone: 306-955-2633 Saskatoon Wellness Centre Fax: 306-955-2638 1814 Lorne Ave., Saskatoon, SK S7H 1Y4 Name Date of Birth / / Age (dd/mm/yy) Sex Marital Status Saskatchewan
Name Date of Birth. City Province Postal Code. Phone # home mobile Phone # (wk) Okay to leave a message re: appointments?
Successful healthcare and preventive medicine require a healthy relationship between provider and patient. Your responses to the following questions will significantly contribute to your doctor's understanding
OKANAGAN HEALTH & PERFORMANCE Inc.
OKANAGAN HEALTH & PERFORMANCE Inc. Chiropractic, Massage Therapy, Kinesiology, Physiotherapy, Acupuncture, Naturopathic Medicine & Osteopathy 104-1100 Lawrence Ave, Kelowna, BC, V1Y 6M4 (250) 860-6295
What else would you like to see changed in his/her health?
Simmonds McMurrer Naturopathic Medicine Dr.Kali Simmonds,N.D. Dr.Lana McMurrer,N.D. Dr.Nara Simmonds,N.D. 34 Queen Street, 2nd Floor Charlottetown, PE C1A 4A3 Tel.902.894.3868 Fax.902.894.4054 www.simmondsmcmurre.com