Birch Wellness Center

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Dr. Kelly Brown drkbrownnd@gmail.com Birch Wellness Center 34 Carlton Street, Winnipeg, Manitoba R3C 1N9 204 505 0325 (f) 204 505 0327 Full Legal Name: (Last, First) / Preferred Name: Date of Birth: Age: Gender: Female Male Other E-mail Address: Address: Telephone: home /work /cell Occupation: Full Time Part time Student Retired Emergency Contact: Names of other Healthcare Providers: Medical Doctor Chiropractor Naturopathic Doctor Others Your Main Health Concerns Why are you seeing the Naturopath today? What are your most important health concerns? Please list in order of importance: 1. 2. 3. Please list vitamin/mineral/herbal supplements you are taking: Supplement/Brand Dose How long have you been taking this supplement?

Please list all current medications: Medication Dose How long have you been taking this medication? Check each that you currently use: Laxatives Pain relievers Antacids Cortisone Antibiotics Heart/Blood medication Allergy medication Thyroid medication Sleeping pills Anti-depressants Birth control pills Hormones Please list any past medications: Your past medical history: (Please list any surgeries or illnesses)

Family Medical History Father Mother Brothers Sisters Children Maternal Grandparents Paternal Grandparents Age (if living) Current Health Age at death Cause of death Social History: How many cigarettes do you smoke a day? How much alcohol do you drink per week? Do you take recreational drugs? (Please list) Are you exposed to any toxins or chemicals in your home or at work (mold, chemicals, etc)? Have you been vaccinated? Which vaccines? Have you travelled recently and to where (Please include Manitoba/North America)? How often do you exercise? What type of exercise do you do?

Diet: (Please complete One week diet diary attached to this form) Are you or have you ever been on a restricted diet? If so, what kind? How much water do you drink/day? What else do you drink? (Tea, juice, coffee, soda, etc.)/day? How frequently do you move your bowels? Per day/week Diet Diary- attached to back of intake Please check boxes that apply, if symptoms are current or past recurring problem: GENERAL Fatigue Change in appetite Change in thirst Cravings Weight gain Weight loss Poor sleep Chills or fever Night sweats Allergies Cancer Diabetes SKIN AND HAIR Dryness Eczema Psoriasis Acne Recent moles Hives/allergic reactions Loss of hair Thinning of hair Dandruff EYES, EARS, NOSE, AND THROAT Eye pain Eye strain Blurry vision Impaired vision Cataracts Ear aches Ear infections Ringing in ears Vertigo/dizziness Sinus infections Nasal obstruction Post nasal drip Nosebleeds Loss of smell/taste Sores in mouth Mercury fillings Jaw pain or clicks Recurrent sore throat Tonsillitis Enlarged glands Enlarged thyroid Facial pain/tics Headaches

CARDIOVASCULAR Chest pain Palpitations High/low blood pressure Heart Attack Irregular heartbeat Pacemaker Congestive heart failure Artificial heart valve Stroke Fainting Varicose veins Deep leg pain Swelling of limbs Low iron Easy bruising RESPIRATORY Difficulty breathing Shortness of breath Chronic cough Bronchitis Emphysema Asthma Wheezing Coughing blood/phlegm MUSCLES, BONES, AND JOINTS Neck/Back pain Arthritis Bursitis Joint pain/stiffness Artificial joint Muscle pain Muscle weakness GASTROINTESTINAL Nausea Vomiting Vomiting blood Reflux or heartburn Constant hunger Ulcers Abdominal pain/cramping Bloating Gallbladder stones Liver disease Intestinal parasites Gas Constipation Diarrhea Chronic laxative use Rectal pain/burning Hemorrhoids Blood in stool NEUROLOGICAL Anxiety Depression Irritability Emotional problems Loss of balance Poor memory Dizziness Seizures/epilepsy Concussions Lack of coordination Extremity numbness Extremity tingling Paralysis

INFECTIONS Strep throat Mononucleosis (Mono) Tuberculosis Hepatitis HIV/AIDS Sexually transmitted Infections URINARY Frequent urination Urgency to urinate Incontinence Pain on urination Waking at night to urinate Urinary tract infection Blood in urine Kidney stones MALE REPRODUCTIVE Prostate problems Impotence Sores on genitals Discharge Testicular mass Testicular pain Hernia Infertility/low sperm FEMALE REPRODUCTIVE Irregular Periods Heavy, light, clots (please circle) Painful periods PMS Sore breast with period Infertility Vaginal sores Vaginal discharge Date of last Pap: Have you had an irregular pap? Age at first menses (period): If yes, what was the date? Age at last menses (If menopausal): Are you menopausal Y/N Currently pregnant or trying Y/N Currently breast feeding Y/N Do you practice birth control Y/N If yes, what type? Number of: Pregnancies Abortions

Miscarriages Births Breasts Lumps Tenderness Nipple discharge Do you do self breast exams? Y/N Sunday Monday Tuesday Wednesday Thursday Friday Saturday Breakfast Lunch Dinner Other/ Snacks

Consent Form Full Legal Name: (Last, First, Middle Initial): There are some slight risks to treatment by Naturopathic Medicine. These include but are not limited to: -Potential allergic reaction to supplements or herbs, -Some aggravation of pre-existing symptoms as a part of healing when using homeopathic remedies I understand the Naturopathic Doctor will answer any of my questions that I have, to the best of their ability. I understand that the results are not guaranteed. I do not expect the doctor to be able to anticipate and explain all risks and complications. With this knowledge, I voluntarily consent to treatment by my naturopath. I understand this consent form will cover the entire course of treatment. I understand I am free to withdraw their consent and discontinue participation in these procedures at any time. Signature of Patient/Guardian: Date:

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