Sandra Cross RNCP, RBIE. First Name: Last Name: Age: Birth Date: Sex: Male Female

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Transcription:

Sandra Cross RNCP, RBIE ADULT INTAKE FORM First Name: Last Name: Age: Birth Date: Sex: Male Female Street Address: City: Province: Postal Code: Phone: (Home) (Work) (Cell) May we leave a message? Yes No E-Mail Address: Would you like to receive our electronic quarterly newsletters: Yes No Occupation: Employer: Marital Status: Single Married Divorced Separated Common Law Widowed Number of Children: Date of last Physical Exam and bloodwork: Emergency Contact Name : Relation: Phone: How did you hear about our clinic? What is your main reason for coming in today? List other health problems that are troubling you: 1) When did it start? 2) When did it start? 3) When did it start? 4) When did it start? 1

HEALTH HISTORY: What is your general state of wellbeing from 1-10? (10 is the highest) What is your level of commitment to your wellbeing? 1-10? (10 is the highest) On average, how would you rate your energy level from 1-10 (10 is the highest) Please list previous surgeries (include dates if possible) Please list any allergies to drugs, plants, foods, animal or other? Please list current supplements and/or medications: _ Were you vaccinated? If so, any adverse reactions? Please list: Please check if you consume: Alcohol Artificial Sweeteners Coffee/caffeine Recreational Drugs Soda Pop Tobacco FAMILY HISTORY: Mother Father Age if Living Age at Death Cause of Death Health Concerns Brother(s) Sister(s) Maternal Grandmother Maternal grandfather Paternal Grandmother Paternal Grandfather 2

Please indicate which, if any, of the following you have had either Now (N) or in the Past (P): Allergies Ear Infection Malaria Sexual abuse Abscesses Eczema Measles Sleeping Problems Alcoholism Emotional abuse Mental illness Small pox Anemia Epilepsy Migraine Strep throat Arthritis Fainting Miscarriage Stroke Asthma Fatigue Mono Syphilis Balance issues Fungal Infections Mumps Thyroid issues Bladder infections Gallstones Numbness or tingling Tonsillitis Broken bone Gas/bloating Parasites Tuberculosis Bronchitis Gout Pelvic Inflammatory Varicose veins Disease Cancer Hay fever Physical abuse Venereal disease Chicken pox Headache Pneumonia Vision issues Child abuse Heart disease Poor memory Warts Chronic Sore Hemorrhoids Rape Weight issues Throats Cold hands/feet Hepatitis Rectal bleeding Whooping cough Depression Herpes Rheumatic fever Worms Diabetes High blood Ringing in ears Other: pressure Diphtheria Jaundice Scarlet fever PERSONAL HABITS/LIFESTYLE: Do you exercise? Y/N What forms? Do you have sleep problems? Y/N Please describe How many hours of sleep do you get per night? Do you wake refreshed? Y/N Do you sweat at night? Y/N How is your general body temperature? Warmer Cooler Average How much water do you drink per day? Is your home damp or moldy at all? Y/N Do you work in the presence of toxic fumes or materials? Y/N Do you use a microwave? Y/N OTHER: What long term expectations do you have from working with our clinic? What expectations do you have of me personally as your practitioner? Is there any other information you think is important for me to know? 3

Welcome to Sage Naturopathic Clinic! ABOUT US At Sage Naturopathic Clinic, we want people to feel better. Our vision is to create a safe space for all our patients in which they can strive for their optimum health. We know that in today s world, striving for optimum health is not easy it s incredibly challenging. At Sage, we work to empower our patients to feel the best they can feel. We aim to educate our patients so that they can make the most informed decisions about their care. PRIVACY POLICY Privacy of your personal information is an important part of what we offer at Sage Naturopathic Clinic, and protecting your personal information is something we take very seriously. We are committed to collecting, using and disclosing your personal information responsibly. Only necessary information is collected about you; Only with your consent do we share information with others outside the clinic; Storage, retention and destruction of your personal information complies with existing legislation and privacy protection protocols; Sage Naturopathic Clinic s privacy policy conforms to privacy legislation and standards of the Board of Directors of Drugless Therapy Naturopathy. Personal information is collected in order to: Assess your health; Provide health care; Advise you of treatment options; Establish and maintain contact with you regarding appointments, invoicing and follow-up care; Send you pertinent information and mailings; Facilitate your insurance claims; Allow potential purchasers, practice brokers or advisors to conduct an audit in preparation for a practice sale; Comply with the legal and regulatory requirements of the Drugless Practitioners Act. Signature: Date: Witness: Date: Print parent/guardian s name: (if under 18 years of age) Signature of Parent/guardian: Collaborative Team: At Sage, out healthcare team works to provide the best care possible for our patients. We recognize that in some cases, providing the best healthcare means utilizing the skills of multiple practitioners. In such cases allowing for professional, open dialogue, regarding your case, between members of your healthcare team at Sage Naturopathic Clinic can allow for optimal treatment strategies and improvement in your health. I welcome professional dialogue regarding my case between members of my healthcare team at Sage Naturopathic Clinic: Yes No Signature: 4

Helpful Information for Intolerance Testing 24 hours notice is needed for cancellations or a $30 fee does apply Being well hydrated with water will help the testing and BIE session In cases of severe skin issues, all over body pain, or regular stomach upset - please bring all medications and supplements to your visit. In cases with skin issues or any rashes - please bring all personal care and laundry items. In cases with skin rashes and breathing trouble (where cats/dogs/furry friends are in the home) please bring a good hair sample in a well sealed sandwich bag. Keep family pet samples separate. Various parts of the body are used - including the feet Jewellery, watches and nylons will need to be removed ahead of time if worn. Small earrings or piercings are not a concern. Please avoid wearing clothing with an excessive amount of metal decor/design Methods of payment are cash, Debit, Visa, Mastercard 5

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