Patient Information. How did you hear about the BIHC: If you were referred, please state by whom: If yes, by whom: Date of last visit: DD/MM/YYYY

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Lauren McLaughlin
5 years ago
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Dr. Kelly Gillis, ND Doctor of Naturopathic Medicine Patient Information Date of initial appointment: DD/MM/YYYY Name: Address: Age: Date of Birth: DD/MM/YYYY Sex: M F Gender (if different than sex):

1 Dr. Kelly Gillis, ND Doctor of Naturopathic Medicine Patient Information Date of initial appointment: DD/MM/YYYY Name: Address: Age: Date of Birth: DD/MM/YYYY Sex: M F Gender (if different than sex): Occupation: Employer: Emergency contact name: Relationship: Emergency contact phone number: ( ) 1 - Phone #: ( ) Home Work Cell 2 - Phone #: ( ) Home Work Cell Preferred method of contact: Phone ( 1 or 2 ) Do not contact May we leave messages regarding your visit? How did you hear about the BIHC: If you were referred, please state by whom: Have you ever been treated by a naturopathic doctor before: If yes, by whom: Date of last visit: DD/MM/YYYY Date of last physical exam: DD/MM/YYYY Health Goals Please list your major health concerns/goals in order of importance: 1._ 2._ 3._ 4._ 5._

2 Medical History Please indicate any serious illnesses/injuries/hospitalizations with approximate dates: Childhood illnesses (check all that apply): Asthma Chicken pox Scarlet fever Polio Rheumatic fever Whooping cough Rubella (German measles) Mumps Measles Roseola Vaccination history (Bolded vaccines are considered routine as per the Ontario Childhood Vaccination schedule) check all that apply: DPT (Diptheria, Pertussis, Tetanus) MMR (Measles, Mumps, Rubella) Hepatitis B Polio Pneumococcal conjugate (meningitis / pneumonia) Meningococcal C Conjugate (meningitis) Varivax / Varilrix (chicken pox) Gardasil / Cervarix (HPV vaccine) Haemophilus Influenza B BCG (Tuberculosis) Hepatitis A Flu vaccine Other: List any CURRENT medications, including over the counter medications, supplements, vitamins, minerals, herbs and homeopathics: Medication/supplement name Dose and Brand

3 List any PAST medications, including over the counter medications, supplements, vitamins, minerals, herbs and homeopathic remedies: Medication/supplement name Dose and Brand Start date Stop date List all ALLERGIES including environmental, food, pharmaceutical/supplement, etc. and describe your reaction: Allergy Reaction Indicate if you currently have, or have had in the past, any of the following by checking all applicable boxes. Please provide the approximate date: AIDS/Positive HIV Hypothyroidism Allergies Urinary tract infections Anemia Kidney/Bladder Infections Anxiety Other mental illness not listed Asthma Arthritis Mononucleosis Colitis Abnormal PAP results Convulsions/Seizures Polio Depression Psoriasis Diabetes Prostate Condition Eating Disorder Rheumatic Fever Eczema STI Endometriosis Stomach/Duodenal Ulcer Headaches/migraines Tuberculosis Heart Disease Urinary Tract Infections Heart Murmur Vaginitis Hepatitis Other High Blood Pressure Other Hyperthyroidism Other

4 Family Medical History Check any known health concerns for each family member and write in which family member(s) has been affected. List any other known health concerns in the table below: Cancer (type ) High blood pressure Diabetes (Type 1/Type 2) Stroke Heart disease Thyroid problems Depression Autoimmune disease Anxiety Kidney disease Other mental illness Alcohol/drug abuse Mother Father Siblings Maternal grandmother Maternal grandfather Paternal grandmother Paternal grandfather Diet and Lifestyle List any dietary restrictions or allergies: Diet Caffeine Alcohol 24hr diet recall: Breakfast: Lunch: Dinner: Snacks: Beverages: Number of cups of the following consumed in a day: Coffee: Tea: Juice: Cola: If yes, how many drinks per week? Do you consume alcohol? What type(s) of alcohol do you consume? Do you use tobacco? If yes, how many times per day? Tobacco What type(s) of tobacco? Have you even been exposed to second hand smoke for extended or regular periods? Do you use recreational drugs? How many years? If yes, for how long?

5 Drugs Exercise Stress Energy Sleep Relationships and sexuality Lifestyle If yes, which kind(s) and how often? How many times per week do you exercise? >7 What type of exercise do you prefer? Rate your stress from 0-10 (0 = no stress, 10 = extremely stressful) What are the major sources of stress in your life: Rate your energy from 0-10 (0 = no energy, 10 = most energetic) Time of day for best energy: Time of day for lowest energy: What are your typical sleeping hours? From am/pm to am/pm Do you have trouble falling asleep? Do you awake feeling refreshed: What times do you wake up during Do you have trouble staying asleep? the night? Sexual orientation: Are you currently pregnant? Are you currently breastfeeding? If female: What types of hobbies and activities do you do? Where have you travelled? Do you have any pets, or are you exposed to any animals?

Patient Intake Form - Child. Last Name: First Name: Middle Name: Birth Date (dd/mm/yyyy): Age: Sex: Who is filling out this form? (name, relationhip):

Patient Intake Form - Child. Last Name: First Name: Middle Name: Birth Date (dd/mm/yyyy): Age: Sex: Who is filling out this form? (name, relationhip): Patient Intake Form - Child Dr. Daria Novy, ND 2-228 Second St. West Cornwall, ON K6J 1G7 T: 613 938-9500 F: 855 820-1240 Last Name: First Name: Middle Name: Birth Date (dd/mm/yyyy): Age: Sex: Who is filling