Name: Gender: m F m M. Mother s full name: Telephone: (work) (mobile) Father s full name: Telephone: (work) (mobile) Name: Telephone:
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1 Du La, ND# 1135 Jonah Lusis, ND# 1248 T: Pediatric Intake Date: Name: Gender: m F m M Age: D.O.B.: Address: City: Postal Code: Telephone: (home) Mother s full name: Telephone: (work) (mobile) Father s full name: Telephone: (work) (mobile) Other emergency contact: Name: Telephone: Relation: Is your child currently under the care of a medical doctor? m Y m N Name: Telephone: How would you prefer to be addressed at the Clinic? How did you hear about us? Would you like to be added to our list to be informed of free lectures or other events presented by Toronto-Centre Naturopathic Medicine? m Y m N CURRENT HEALTH CONCERNS What are your child s health concerns (in order of importance to you)? Have any of these conditions recently changed or become worse? What effect has this had on your child s life? What is your child s general state of health? page 1 of 7
2 Do you have any major concerns regarding your child s health? What is your child s greatest health concern (in their opinion)? Known allergies: MEDICATIONS AND SUPPLEMENTS Please list all prescription and non-prescription medications, including dosage, efficacy and adverse reactions Please list all supplements, homeopathic remedies, etc. including dosage, efficacy and adverse reactions. 2. Previous treatments: (Include treatment, date and efficacy of treatment) CURRENT HEALTH PROFILE Height: Weight: Max. weight: Date of max. weight: Foods avoided: Why: Food cravings: Dairy consumption: m Y m N servings daily Soft drink consumption: m Y m N 8 oz. servings/day What is the source of your household s drinking water? m tap m filtered m distilled m bottled spring page 2 of 7
3 If you have not completed in a Weekly Diet Journal for your child, list their dietary intake for the last 24 hours. B: L: D: How many bowel movements does your child have daily? If your child is presently breastfed, list your/your partner s (i.e., your child s mother) dietary intake for the last 24 hours. B: L: D: Regular exercise: m Y m N Type: Duration: Frequency: How much time does your child spend watching television/using a computer on a typical day? How much time does your child spend outdoors daily? Does your child enjoy school? If no, why not? Has your child ever experienced an emotional trauma? If yes, describe. Does your child (experience): Sleep problems: m Y m N Date/duration: Nightmares: m Y m N Date/duration: Bedwetting: m Y m N Date/duration: Sleep excessively: m Y m N Date/duration: Other sleep problems: Is your child exposed to any of the following (at home or at school)? m tobacco smoke m pets m old building m renovations m chemical fumes Elaborate: GENERAL INFORMATION Describe your child s personality/disposition. page 3 of 7
4 What are your child s interests/hobbies? Please describe any limitations to care that I should be aware of (e.g., time restraints, dietary restrictions). PAST HEALTH HISTORY Has your child ever been diagnosed with a medical condition? Elaborate: Vaccinations/Immunizations: (Complete appropriate boxes) Vaccine Age(s) Adverse reactions Hep. B DPT Hib Polio Influenza MMR Varicella Has your child ever used antibiotics? m Y m N Date/dosage/duration: For what condition? CHILDHOOD ILLNESS m chicken pox m polio m rubella m tuberculosis m measles m rheumatic fever m scarlet fever m whooping cough m mumps Hospitalizations, surgeries, serious injuries: (Include date and reason for hospitalization) OBSTETRIC HEALTH HISTORY BIRTH HISTORY At what age did you/your partner (i.e., your child s mother) give birth to your child? Was this child your/your partner s (i.e., your child s mother) first pregnancy? m Y m N If no, where is this child in the birth order? page 4 of 7
5 Did you and your partner have any difficulty conceiving? m Y m N On a scale of 1-10 (10 = highest), what was the health of you and your partner at your child s conception: Mother Father Describe any health problems you/your partner (i.e, your child s mother) experienced during the pregnancy. What was your/your partner s (i.e., the child s mother) emotional state during the pregnancy? Did you/your partner (i.e., your child s mother) use any of the following during the pregnancy: Medications: m Y m N If yes, which/dosage/duration: Tobacco: m Y m N If yes, pack(s)/day: Alcohol: m Y m N If yes, serving(s)*/day: Recreational drugs: m Y m N If yes, which/how often: Were you/your partner (i.e., your child s mother) exposed to any workplace chemicals during pregnancy? m Y m N If yes, which ones? *1 serving of alcohol = 1.5 oz. spirits, 4 oz. wine, 12 oz. beer (i.e., 1 standard serving) Where did the birth happen (e.g., other country, home, etc.)? How long was the labour? Were there any complications at childbirth (e.g., breech)? m Y m N If yes, describe. Were any interventions employed during the labour or delivery (e.g., forceps)? m Y m N If yes,describe. Birth weight: Birth length: APGAR score (1 min.): APGAR score (5 min.): Age at first: sitting crawling teething walking talking What was your child s general appearance at birth? At/in the first few weeks following birth, did your child experience any of the following: m congenital birth defect m fever m feeding difficulties m skin conditions m infection m jaundice page 5 of 7
6 FEEDING HISTORY Was your child breastfed? m Y m N If yes, until what age? ; if no, what type of formula was used (e.g., commercial brand, homemade, etc.)? At what age were solid foods introduced? Were you selective in which foods were introduced first? m Y m N If yes, describe. Were there any allergy-type reactions to any foods introduced? If yes, describe. Describe your child s present eating habits. FAMILY HEALTH HISTORY Please check appropriate boxes for immediate family (i.e., grandparents, parents, siblings). m allergies/hay fever m eating disorders m psychiatric illness m asthma m epilepsy m obesity m arthritis m gout m stroke m bleeding problems m heart problems m substance abuse m cancer m high blood pressure m thyroid problems m diabetes m kidney problems m tuberculosis Age and health status of immediate family: Mother: Father: Maternal grandmother: Maternal grandfather: Paternal grandmother: Paternal grandfather: Is there anything else I should be aware of? page 6 of 7
7 REVIEW OF SYSTEMS Please circle Y if your child is presently experiencing a symptom/condition and P if they have experienced it in the past. GENERAL fatigue/weakness Y P fever/chills Y P HAIR/SKIN/NAILS cradle cap Y P skin dryness Y P yellowing Y P itching Y P rash/hives Y P boils Y P acne Y P eczema Y P psoriasis Y P warts Y P diaper rash Y P nail ridging/spots Y P HEAD headaches Y P injury Y P Other: EYES impaired vision Y P pain Y P itching Y P dryness Y P tearing Y P redness Y P discharge Y P Latest eye exam: EARS impaired hearing Y P earache Y P itching Y P discharge Y P excessive wax Y P infection Y P dizziness Y P NOSE/SINUSES bleeding Y P congestion Y P obstruction Y P hay fever/ allergies Y P sinus problems Y P injury Y P Other: MOUTH/THROAT dental caries Y P gum problems Y P chancre sores Y P frequent sore throat Y P tonsillitis Y P thrush Y P Latest dental exam : RESPIRATORY cough Y P bloody sputum Y P wheezing Y P difficulty breathing Y P asthma Y P bronchitis Y P pneumonia Y P CARDIOVASCULAR cold hands/feet Y P heart murmur/ palpitation Y P rheumatic fever Y P BLOOD fatigue/weakness Y P skin paleness Y P easy bleeding/ bruising Y P clotting problems Y P blood transfusion Y P anemia Y P Other : GASTROINTESTINAL abdominal pain Y P indigestion Y P belching/flatulence Y P nausea Y P vomiting Y P constipation Y P diarrhea Y P hemorrhoids Y P URINARY genital itching Y P discoloured urine Y P bedwetting Y P MUSCULOSKELETAL pain Y P fractures Y P NEUROLOGICAL numbness/ tingling Y P muscle weakness Y P involuntary movements Y P paralysis Y P fainting Y P convulsions Y P Other : ENDOCRINE/METABOLIC hypoglycemia Y P diabetes Y P PSYCHOSOCIAL hyperactivity Y P sleep problems Y P phobias Y P depression Y P anxiety Y P page 7 of 7
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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
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
DATE OF BIRTH: MELANOMA INTAKE
MELANOMA INTAKE GENERAL INFORMATION How was your first diagnosed? (Check the diagnosis that describes your condition.) Melanoma Merkel Cell Carcinoma Squamous Cell Carcinoma Basal Cell Carcinoma Other
Holistic Health Care New Patient Intake Form
Holistic Health Care New Patient Intake Form Name * Address * Telephone number: * Email Address * May we use your email address occasionally for health related information? * Are you a current or past
Adult Naturopathic Intake Form
Alternative Health Empowerment, Inc. 670 Colonial Road, Suite 5 Memphis, Tennessee 38117 (901) 683-8200 / www.ahe4life.com Personal Information Date: Name: Age: Birth Date: Sex: M F Address: City: State:
Health Intake Form. Name: Prefer Name: Date: City: State: Zip Code: Gender: M F. Telephone # (home): (work): (Cell):
Health Intake Form Name: Prefer Name: Date: Address: Age: City: State: Zip Code: Gender: M F Telephone # (home): (work): (Cell): Email Address: Date of Birth: Marital Status: Married Separated Divorced
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
Patient Information Form
Tara Annesley B.Sc., N.D., C.Ht. Patient Information Form Today s day/month/year Name: (first) (middle) (last) Address: City: Postal Code: Telephone Home: Work: Cell: Date of birth: day/month/year Age:
Dr. Michelle Mackay Patel, ND
NATUROPATHIC ADULT INTAKE PERSONAL INFORMATION: First Name(s): Last Name: Date of Birth (mm/dd/yy): / / Age: What is your current gender identity? Male Female Transgender Male/Transman/FTM Transgender
MEDICAL ASSESSMENT PART 1 - SOCIAL HISTORY
Smoking history Alcohol history Never Quit Never Quit PART 2 - MEDICAL HISTORY Date of last colonoscopy? Date of last mammogram? Date of last pap smear? Date of last flu vaccine? Date of last pneumonia
DR. CESTNICK ADULT BACKGROUND QUESTIONNAIRE. Birth date: Age: Sex (circle one): Male Female. Home address: City: Zip Code:
DR. CESTNICK ADULT BACKGROUND QUESTIONNAIRE Your name: Today s date: Birth date: Age: Sex (circle one): Male Female Home address: City: Zip Code: Phone: Home # Cell # Other # Email: School (if student):
Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
Appointment Date: Page 1 Chief Complaint: (Please write reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History PERSONAL SKIN HISTORY YES NO Yes - Details Melanoma
Ageless Acupuncture Patient Health History
Ageless Acupuncture Patient Health History Name: Date: By what name would you like us to refer to you?: Street Address: City: State: Zip Code: Home Telephone: Work Telephone: Cell Phone: How early/late
GoPrivateMD General Information & History
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.
Pure Health Natural Medicine
Pure Health Natural Medicine Female Intake Date: Personal Information Name: (first, last) Maiden: Preferred Name: Sex: M F Date of Birth: Age: Street Address: City: State: Zip: E-mail Home Phone: Cell
Medical History Intake Form
Medical History Intake Form What is your opinion of your overall level of health? Excellent Good Fair Poor In your opinion (not necessarily your health care providers), what are your most important health
Patient Medical History Form
Patient Medical History Form Name: DOB: Sex: M F Street Address: City: State: Zip: Home Phone: Work Phone: Cell Phone:_ Email: Emergency Contact: Phone: Primary Care Physician: Phone: How did you hear
GENERAL INFORMATION (Please print)
APPLICATION FORM & QUESTIONNAIRE GENERAL INFORMATION (Please print) Today's date Name Age Sex (M,F) Place of birth Birth date Marital status Number of children Living situation (alone, family, friends)
Rooted 93 Bell Farm Rd. unit Naturopathic Medicine INTAKE FORM. What number may we leave messages at? Emergency contact: Phone:
PERSONAL INFORMATION Rooted 93 Bell Farm Rd. unit 103 705.792.6717 Naturopathic Medicine INTAKE FORM Name: Date: Date of Birth: Age: Sex/gender: Home Address: City: Home Telephone: Postal Code: Other Telephone:
Questionnaire for Lipedema Patients
Questionnaire for Lipedema Patients Name Date of diagnosis Date Name of physician making diagnosis Do you also have lymphedema? What areas of the body are affected? Outside of thighs Inner thighs Knees