HEALTH APPRAISAL QUESTIONNAIRE DR. BRIAN JOHN DAVIES. Name: Birthday (D/M/Y): Age: Male: Female: (First) (Initial) (Last)

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1 Lonsdale Ave, NORTH VANCOUVER, B.C. V7M 2E6 PHONE: (778) FAX: (778) Patient Information HEALTH APPRAISAL QUESTIONNAIRE DR. BRIAN JOHN DAVIES Name: Birthday (D/M/Y): Age: Male: Female: (First) (Initial) (Last) Address: (Street) (Apt/Ste #) (City) (Postal Code) Home phone: Work/Cell Phone: Single: Married: # of Children: Occupation: _ Parent's name (if a minor): Referred by: In case of emergency Name: Relationship: Contact Number(s): Current Health Concerns What are your health concerns in order of appearance 1) 2) Medical History Past illnesses, conditions, and hospitalizations: 3) 4) List supplements you are currently taking: _ Allergies or sensitivities (food, drugs, seasonal, pets, etc.) Females: Are you currently pregnant? Date of last physical exam: Family History- Please indicate if a close relative (parent, child, sibling, grandparent) experiences the following: Allergies Depression Asthma Heart disease High blood pressure Cancer Diabetes Other mental illness (specify) Drug abuse Alcoholism Kidney disease Family MD: Address: Phone: Other

2 Part I Check Circle any of the following medications you are taking or have taken: Antacids Antibiotic/Antifungal Antidiabetic/lnsulin Aspirin/Tylenol Cortisone/Antiinflammatory Heart Medications Blood Pressure Hormones Antidepressants Chemotherapy Other Vaccinations - DPT Chicken pox Flu Hep A/B MMR Polio Hib Laxatives Lithium Oral Contraceptives Radiation Recreational Drugs Specify Relaxants/Sleeping Thyroid Ulcer Medications Check Circle if you eat, drink or use: Alcohol Carbonated beverages Coffee Fast food regularly Lunch meats Refined sugars Candy Cigarettes Distilled water Fried foods Margarine Sugar substitutes Check Circle if you: Diet Often Do not exercise regularly Salt food without tasting Are under excessive stress Have mercury or silver fillings Are exposed to chemicals at work Are exposed to cigarette smoke INSTRUCTIONS: Check Circle the number which best describes your symptoms. If you do not know the answer to a question, leave it blank. 0= Past 1 = Mild 2= Moderate 3 = Severe Part II 1. Burping Prolonged fullness after meals Bloating Poor appetite Stomach upsets easily History of constipation Known food allergies Abdominal cramps Indigestion 1-3 hours after eating Fatigue after eating Lower bowel gas Alternating constipation and diarrhea Diarrhea Roughage and fiber causes constipation Mucous in stools Stool poorly formed Shiny stool Three or more large bowel movements /day 12. Foul smelling stool Dry flaky skin and/or dry brittle hair Pain in left side under rib cage Acne Food allergies... Part III 1. Intolerance to greasy foods Headaches after eating Light colored stool Foul smelling stool Less than one bowel movement daily Constipation Hard stool Sour taste in mouth Grey colored skin Yellow in whites of eyes Bad breath Body odor Stomach pains Stomach pains just before/after meals Dependency on antacids Chronic abdominal pain Butterfly sensations in stomach Difficulty belching Stomach pain when emotionally upset Sudden, acute indigestion Relief by carbonated beverages Relief of stomach pain by drinking milk History of ulcer or gastritis Current ulcer..: Black stool when not taking iron supplements SECTION D: 1. Seasonal diarrhea Frequent and recurrent infections (colds) Bladder and kidney infections Vaginal yeast infection Abdominal cramps Toe and fingernail fungus Alternating diarrhea/constipation Constipation History of antibiotic use Meat eater...' Rapidly failing vision Fatigue and sleepiness after eating Pain in right side under rib cage Painful to pass stool Retain water Big toe painful Pain radiates along outside of leg Dry skin/hair Red blood in stool Have had jaundice or hepatitis High blood cholesterol Is your cholesterol level above Is your triglyceride level above (10) (5) (10)

3 Part III (Cont.) 1. Swollen eyes (bulging) Strong smelling urine Thick skin and finger nails Dry skin Sensitive to the cold Cold hands and feet Excessive menstrual bleeding Chronic fatigue Trouble waking up in the morning Depressed, apathetic Low sex drive Puffy, wrinkly skin Sugar causes irritability and mood swings Premenstrual tension Constipation Thinning or loss of outside portion of eyebrow 17. Gain weight easily Anemia unaffected by iron Axillary (armpit) temperature below 35C Slow reflexes Infertility... Part IV 1. Sensitive to exhaust fumes, smoke, smog, etc Periodic constipation Cannot tolerate much exercise Depression or rapid mood swings Dark circles under the eyes Dizziness upon standing Lack of mental alertness Catch colds easily when weather changes Difficulty breathing Water retention Eyes sensitive to bright light Feel weak and shaky Inflamed or bleeding gums Running nose Get boils or styes sebleeds Loss of smell Throat infections Cold sores, fever blisters Loss of taste Poor wound healing Hair falls out Swollen lymph glands Ear infection Hair grows slowly Slow to recover from cold or flu Catch colds or flu easily Bumpy skin on back of arms Eczema and psoriasis Asthma/bronchitis Migraine headaches Entire body aches, painful to touch Swollen joints Food sensitivity or allergy Certain foods make you sick, depressed, jittery 8. Chronic pain Painful stomach and/or intestine Alternating constipation and diarrhea Mucous in throat Post nasal drip Discharge from eyes Eyes itch Puffiness or dark circles under eyes Ear discharge or ears stuffed up Sinusitis/Rhinitis Running nose Breathe through mouth Swollen tongue Difficulty swallowing Bed wetting Hyperactivity Chronic lung congestion Use aspirin/tylenol regularly Use Cortisone/Prednisone Total body hair loss (Alopecia)... (10) (10) (10) (5) (5) Part V 1. Shortness of breath Chest pain while walking Heaviness in legs Calf muscles cramp while walking Heart pounds easily Feel jittery Heart misses beats or has extra beats Swelling of feet and ankles Rapid beating heart Heartburn after eating Pain in left arm Exhausted with minor exertion Do you do aerobic exercise? Have you ever exercised regularly? Bright red nose At rest heart beats per minute... (under 80 leave blank) < Cold hands and feet Slurred speech Headaches Numbness in extremities Poor concentration Ringing in ears Ear canal hair Heart attack Stroke Vertical wrinkle in lower ear lobe Pain when getting up in morning in back of head and neck Dizziness Vertigo Fatigue easily Blushing with no apparent cause Is your blood pressure high?... (10) (10) (10)

4 Part VI 1. Dizziness when standing suddenly Loss of vision when standing suddenly Crave sweets Headaches relieved by eating sweets or alcohol 5. Feels shaky Irritable if a meal is missed Wake up in middle of night craving sweets Feel tired or weak if a meal is missed Heart palpitations after eating sweets Need to drink coffee to get started Impatient, moody, nervous Feel tired 1 to 3 hours after eating Poor Memory Poor concentration Forgetful Calmer after eating... 1 Night sweats... 2 Increased thirst... 3 Lowered resistance to infection... 4 Fatigue Boils and leg sores Lesions, cuts take a long time to heal... 7 Overweight Feel more energized after exercise Failing eyesight Crave sweets, but eating sweets does not relieve symptoms Family history of diabetes Sugar in urine... Part VII 1. Chest pain Chronic cough Difficulty breathing Coughing up blood Coughing up phlegm Pain around ribs Shortness of breath Rattling mucous when you breathe Sensitive to smog Infections settle in lungs Work around people who smoke Bronchitis Exposed to chemicals and radiation Smoker... What do you smoke? # per day (10) (5) (5) Part VIII 1. Frequent urination Frequent bladder infections Rarely need to urinate Urination when you cough or sneeze Painful/burning when passing urine Difficulty passing urine Dripping after urination Can't hold urine Rose colored (bloody) urine Cloudy urine Strong smelling urine Back or leg pains associated with dripping after urination History of bladder infections Have used antibiotics to control urinary tract infections... IF YES. WHEN DID YOU LAST USE THEM? TREATMENT DURATION Part IX (Males Only) 1. Difficulty urinating A sense of bladder fullness Increased straining with smaller and smaller... amounts of urine passed Rose colored (bloody) urine Pain or burning while urinating Wake up to urinate at night Dripping alter urination Pain or fatigue in the legs or back Lack of sex drive Ejaculation causes pain Difficulty attaining/maintaining an erection 2. Anxiety or fear of sexual intimacy with women 3. Premature ejaculation Pain/coldness in genital area Infertile Varicose veins on scrotum Low sperm count Discharge from penis Past or present rash on penis Swollen genitals Swelling in groin Venereal disease (gonorrhea, syphilis, herpes or other)... Do you have V.D. w? (5) (5) (5) Had in past? Part X (Females Only) Circle if you experience any of these symptoms within roughly 2 weeks (ovulation) prior to menstruation. (Section A only) 1. Monthly weight gain Depression Moodiness/irritability Bloating and swelling Nausea and/or vomiting Suicidal feeling Anxiety Leg cramps and tenderness Asthma attacks Headaches... (10) (10) 11. Easily distracted Anger Tender breasts Low backache Other 1. Vaginal itching Vaginal discharge LOW or no sex desire Dislike for intercourse Missed periods... 6.Over 15 yrs of age when menstruation began..

5 Part X Section B continued (Females Only) 7. Unable to get pregnant Miscarriages Abortion... Check if you experience any of these symptoms during menstruation. (Section C only) 1. Low abdominal pain Dull ache radiating to low back or legs Increased urinary frequency Pelvic soreness Diarrhea Headaches Abdominal bloating Menstrual pain Nausea and/or vomiting Have to lie down on first 1 or 2 days of period. 11. Craving for sweets Insomnia Light scanty blood flow Pain and cramps without blood flow Heavy menstrual bleeding Anxiety about menstrual cycle Pain during menses progressively worsening with time... SECTION D: 1. Vaginal bumps and sores Pubic area sore... How many? How many? 3. Ovarian cysts Uterine cysts Pain in ovaries Breast lumps Breasts sore to touch Breasts painful Water retention Swollen feeling Premenstrual breast pain or discomfort Mother used D.E.S. (hormones) while pregnant Recent pap smear positive Family history of breast cancer Form of birth control: ne Pill Diaphragm Foam Other SECTION E: 1. Hot flashes Night sweats Hysterectomy Depression/Mood Swings Insomnia Craving for sweets Heavy bleeding two weeks/month Sweating throughout day Dryness of skin, hair, and vagina Painful intercourse Vaginal pain Vaginal itching Osteoporosis (Bone loss)... (10) (10) (10) (10) Part XI 1. Pain in fingers Bones sore/painful Eat meat Cavities Arthritis Drink carbonated beverages/soda Gum disease Bone loss Calcium deposits Use antacids Dentures Bone deformity Told you have osteoporosis/osteomalacia Recent bone fracture Are you post menopause Muscle spasms Tightness in shoulder muscles... Amount/week L # per week (10) 3. Muscle cramps Pain in arms, hands Leg cramps at night Stiff all over Stiff in morning Unable to sit straight Pain in neck and/or shoulders Over flexible joints (double-jointed) Back pain Swollen knees/elbows Athletic injury Bursitis Tendonitis Joint pain Slipped disc Herniated disc Loss in height Injure easily... (5) (10) Part XII 1. Head feels heavy Light headedness/fainting... 1 Loss of balance Dizziness Ringing/buzzing in ears... 6.Trembling hands Loss of feeling in hands and/or feet (toes) Exhaustion on slightest effort Limbs feel too heavy to hold up Loss of grip strength Tingling pain sensation 'Convulsions Incoordination Nervousness Accident-prone Loss of muscle tone Need for hours sleep/night Have had shingles... Part XIII 1. Nightmares Can't fall asleep Intense dreams Leg cramps/restless leg at night Restless. uneasy sleeper Wake frequently throughout night Wake up in the middle of night, can't fall back to sleep Sleep walk Do you have any other symptoms that have not been covered in the questionnaire?...

6 LONSDALE AVE, NORTH VANCOUVER, B.C. V7M 2E6 PHONE: (778) FAX: (778) DR. BRIAN JOHN DAVIES ND BSc INFORMED CONSENT FOR NATUROPATHIC TREATMENT AND POLICIES Consent for Naturopathic treatment is requested to allow for treatment to be recommended and administered. All suggested treatments will be discussed prior to recommendation. If you have any questions about a specific recommendation please advise Dr. Davies of this concern in writing or verbally before starting your treatment. Naturopathic Doctors obtain consent to make sure you are aware of possible side effects and risks of treatment. Dr. Davies uses the following modalities in his practice: functional medicine, orthomolecular medicine, botanical medicine, pharmaceutical medicine, homeopathy, intravenous therapy, acupuncture, cold light laser therapy, cryotherapy and lifestyle, diet and nutritional counseling. Even the gentlest of therapies have their complications in certain physiological conditions such as pregnancy and lactation, in very young children, or those taking multiple medications. Some therapies must be used with caution in certain diseases, including, but not limited to diabetes, heart disease, liver disease, and kidney disease. It is very important therefore that you inform Dr. Davies of any of these conditions immediately if applicable. Because each individual may respond differently to treatment, Dr. Davies may not be able to anticipate and explain ALL risks and complications. It is therefore advised to start your treatment slowly, if you are concerned about the possibility of adverse effects. There are some risks to treatment with naturopathic medicine. These include but are not limited to aggravation of pre-existing symptoms, allergic reactions to supplements, herbs, intravenous and oxygen therapies. Pain, bruising, and injury are possible from acupuncture, fainting or puncturing of an organ with acupuncture needles and bleeding, phlebitis, sepsis, nausea and fainting from venipuncture. Cryotherapy is a minor surgical procedure using high pressured liquid nitrogen. Complications of this treatment may include irritation and discomfort at the site of treatment until tissue healing can occur. Oxygen therapy may cause light-headedness and treatment with nebeulized glutathione may exasperate symptoms of asthma. I understand that all information provided during my visit is strictly confidential. Information may only be release upon my written request or as required by law. Cases may only be discussed in a clinical setting for the purpose of education. direct personal information will be revealed about me if my case is discussed. I acknowledge that I have discussed, will discuss or have the ability to discuss, with Dr. Davies the nature and purpose of any prescribed treatment in general and my treatment in particular. I acknowledge that I may request any research or literature that is available for a specific treatment that is recommended to me. I consent to the naturopathic treatments offered or recommended to me by Dr. Brian John Davies, ND. I intend this consent to apply to all my present and future naturopathic care. I have read and understand the above statements regarding potential treatment side-effects. I also understand that there is no guarantee for a specific cure result. I understand that if I miss an appointment or cancel on short notice (less that 24 hours), I will be charged a fee for the missed appointment. This fee is applied to keep the overall costs of office visits as low as possible for all clients of Westcoast Integrative Health Inc. POLICY AND SERVICE GUARANTEE Dr Davies will do his best to respond to all s with as much information as possible. s, with respect to questions about recent treatment recommendations and visit information are encouraged, so please send us an if you have any questions about your treatment or complaints about our service. We want to hear from you and will do everything we can to remedy your concerns. Based on ethical and legal issues, responses may not be provided for discussion of test results or new medical concerns, that may arise, that have not been previously discussed and documented in the office. By signing this consent I, also, understand this policy and its intent to avoid harm through electronic transmission of misinformation. I also consent to receive, via , electronic copies of test results, invoices, visit recommendations, and other documentation pertaining to my treatment, when necessary. Patient Name Signature of Patient or Guardian Date (If applicable) Witness Name Witness Signature