Opti-Balance Naturopathic Medicine Intake Form

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Transcription:

Opti-Balance Naturopathic Medicine Intake Form Personal Information: Name: ( First, Middle, Last ) Birth Date: Age: Blood Type: Gender: M / F Social Insurance Number: Height: Weight: Address: City: Postal Code: Phone: (Home) (Work) (Other) Fax: Email: Occupation: Employer: Employer Phone: Emergency Contact: Phone: Relationship: Medical Coverage: BC Care Card Number: Insurance Company: Phone: Policy or Group Number: Medical Doctor: Name: Phone: How did you find out about Dr. Macart ND? Brochure Yellow Pages Family Doctor BCNA Television Friend Chiropractor Directory Radio Relative Specialist Newspaper Internet Coworker Health Professional Health Food Store Other: List your main health concerns in order of importance / severity? 1. 6. 2. 7. 3. 8. 4. 9. 5. 10.

Medical History: Describe your general state of health: Excellent Good Fair Poor Indicate any serious conditions, illnesses, injuries, surgeries, or hospitalizations including approximate dates: Please list all current medications: (Include all prescriptions, over the counter products, vitamins, herbs, homeopathics, etc.) Please list past medications: (Include all prescriptions, over the counter products, vitamins, herbs, homeopathics, etc.) How often do you use any of the following? Aspirin Alcohol Caffeine Diet pills Hormone therapy Laxatives Pain killers Recreational drugs Tobacco How many times have you been treated with antibiotics? What immunizations have you had and any adverse reactions? DPT (diphtheria/pertussis/tetanus) HiB / Meningococcal Tetanus (booster) Gardasil MMR (measles / mumps / rubella) Other

Hemophilius influenza B Flu Polio Hepatitis A Hepatitis B Smallpox Shingles Do you have any allergies, sensitivities, or intolerances? Please explain. Medications Animals Feathers Molds Perfumes Latex Nuts Milk products Eggs Wheat Any Other Please rate your stress level: (Low) 1 2 3 4 5 6 7 8 9 10 (High) Family History: Please indicate which of your close relatives has had any of the following: Alcoholism / Drug Abuse Allergies Asthma Cancer Depression Other mental illness Diabetes Heart problems Kidney problems Dietary Intake: Do you have any dietary restrictions? (allergic, religious, vegetarian, vegan, etc.) Have you ever been on a special diet? If so, please explain.

Review of Systems: Please check boxes for any of the following that you have or have had previously. O = occasional, F = frequent, C = constant O F C General O F C Gastro-Intestinal O F C Cardio-Vascular Allergy Belching or gas Hardening of arteries Chills Colitis High blood pressure Convulsions Colon trouble Low blood pressure Dizziness Constipation Pain over heart Fainting Diarrhea Poor circulation Fatigue Difficult digestion Rapid heart beat Fever Abdominal distension Slow heart beat Headache Excessive hunger Swelling of ankles Loss of sleep Gall bladder trouble Loss of weight Hemorrhoids Respiratory Depression Intestinal worms Chest pain Nervousness Jaundice Chronic cough Neuralgia Liver trouble Difficult breathing Numbness Nausea Spitting up blood Sweats Stomach pain Spitting up phlegm Tremors Poor appetite Wheezing Vomiting Muscle and Joint Vomiting of blood Skin Arthritis Boils Bursitis Eyes, ears, nose, throat Bruise easily Foot trouble Asthma Dryness Hernia Colds Hives or allergy Lower back pain Crossed eyes Itching Lumbago Deafness Skin eruptions (rash) Neck pain or stiffness Dental decay Varicose veins Pain between shoulders Earache Pain or numbness in: Ear discharge Genito-Urinary Shoulders Ear noises Bed-wetting Elbows Enlarged glands Blood in urine Hands Enlarged thyroid Frequent urination Hips Eye pain Poor kidney control Legs Failing vision Kidney infection Knees Far sightedness Kidney stones Feet Gum trouble Painful urination Painful tail bone Hay fever Prostate trouble Poor posture Hoarseness Pus in urine Sciatica Nasal obstruction Spinal curvature Near sightedness Women Swollen joints Nosebleeds Congested breasts Sinus infection Cramps / backache Sore throat Excess menstrual flow Tonsillitis Hot flashes Irregular cycle Lumps in breasts Menopause Painful Menstruation Vaginal discharge Please check the following conditions you have had: Alcoholism Diabetes Heart disease Pleurisy Typhoid fever Anemia Diphtheria Influenza Pneumonia Ulcers Appendicitis Eczema Malaria Polio Venereal disease Arteriosclerosis Emphysema Measles Rheumatic fever Whooping cough Arthritis Epilepsy Miscarriage Scarlet fever Cancer Fever blisters Mono Shingles Chorea Goiter Multiple sclerosis Stroke Cold sores Gout Mumps Tuberculosis

Informed Consent to Naturopathic Procedures Communication with Dr. Macart may occur as office visits, telephone consultations, tele/video conferencing, or email communication. Initial Consultation 55 minutes / $180.00. Neurologically Focused Initial Consultation - $225.00 Initial Consultation Child under 12 $125.00 Return Office Visits - Time based 41-55 minutes / $180 26-40 minutes / $135 11-25 minutes / $95 1-10 minutes / $50 Phone Consultation Time based as above. There will be additional charges for services, products and testing as required. GST will be applied where applicable by law. Fees may be subject to change without notice. All services, products and testing fees require payment at time of service. Because everyone s time is precious, we require 24 hours notice of cancellation. For situations where this does not happen, the full visit will be charged. I clearly understand that Dr. Macart is a naturopathic physician, a specialist in natural therapies and practices. I also understand that her practice and philosophy of medicine may not be in complete accordance with my other health care practitioners and I acknowledge and accept this. I consent to Dr. Macart being my naturopathic physician and that the usual Doctor/Patient privileges and confidentiality apply between Dr. Macart and/or her office or clinical assistants and myself. Please print name: Signature of patient: (or lawful representative) Date:

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