Informed Consent to Naturopathic Therapeutic Procedures Patient Name: Date of Birth: Phone No: Recommended Therapeutic Procedures ( Including those by referral to another practitioner) Nebulized Glutathione Nutritional Supplementation Naturopathic Manipulation Botanical Medicine Acupuncture/Acupressure Homeopathy Hydrotherapy Biopuncture B 12 Injections Dietary/Lifestyle Recommendations IV Therapy TCM ( Traditional Chinese Medicine) I, the undersigned, do hereby acknowledge that I have been informed of and understand the recommended therapeutic procedure( s) described above and have discussed to my satisfaction and any requests for related information with the naturopathic doctor named above and/or with his/her office or clinical assistant( s). I further acknowledge and confirm that I have been informed of, and understand the diagnostic procedures) with respect to the nature of the procedure, expected benefits, potential risks, side effects and financial costs; the likely consequences of not having the procedure( s) and what alternative( s) of action are available to me. As a result, I do hereby voluntarily consent/withhold my informed consent for the recommended therapeutic procedure( s) as specified above. I also understand that I may change the status of my voluntary informed consent at any time. X Patient or Lawful Representative Signature Witness Signature Witness Relation to Patient Attending N.D. Date Signed: Change to Informed Consent I do hereby voluntarily and on an informed basis consent/withhold/withdraw my informed consent for the recommended therapeutic procedure( s) as specified above. I understand that my withholding/withdrawal of the above consent is contrary to the recommendation of my naturopathic doctor. I also understand that I may change the status of my voluntary informed consent at any time. X Patient or Lawful Representative Signature Witness Signature Witness Relation to Patient Attending N.D. Date Signed:
Cancellation Policy In Natural Medical Practice, scheduled visits are significantly longer than in other forms of medicine. As such, missed or inappropriately cancelled appointments can account for a significant amount of loss time over the course of the day. We do not overbook patients in this practice to account for missed or cancelled appointments. It is therefore necessary to enforce the following cancellation policy. You are responsible for the full fee of a missed appointment unless you provide at least 48 hours notice of cancellation for your first visit. For subsequent visits, you will be required to provide at least 24 hours notice for cancellation of your scheduled appointment. We will make every effort to contact you with a reminder of your appointment tine in the days prior to booking and ask that you call the clinic to confirm your appointment time if necessary. During unusual circumstances, such as illness or bad weather, in the absence of adequate cancellation or attendance, you can request that your appointment be conducted over the phone. However, please note that normal visit charges will apply. If you need to cancel or rebook your appointment time, please call 905-417-4000 at your earliest convenience. By signing below you acknowledge your understanding of the above stated cancellation policy. Thank you in advance for your cooperation. Printed Name: Signature: Date:::
Adult Intake Forms Name: Date: Address: Res. # Cell # City: Postal Code: Age: Date of Birth: Email: Occupation: Bus. Tel: Name of Medical Doctor: Are you currently under his/her care? If yes for what? Tel: Emergency Contact Name: Who referred you to our clinic? Tel: Have you been treated by a naturopath before? Yes If Yes, by whom? Why? No When? What is your chief concern? What are your other concerns ( if any) Father: Mother: Sister( s) : Brother( s) : Children: Spouse: Family Medical History
PATIENT S MEDICAL HISTORY Please list below: Immunizations & Reactions ( if any) : CURRENT MEDICATIONS Please circle any of the following medications you are taking: Chemotherapy Recreational Drugs Tranquilizers Radiation Appetite Suppressants Pain Relievers Laxatives Diuretics ( water pills) Sleeping Pills Tobacco Aspirin/Tylenol Antacids Please list and prescription medication, over the counter medications, vitamins, or other supplements you are taking: 1. 4. 2. 5. 3. 6. Please circle if you use any of the following: Alcohol Carbonated Beverages Tap Water Cigarettes Candy/Refined Sugars Spring Water Fried Foods Saccharine Distilled Water Fast Foods Aluminum Pans Coffee Margarine Luncheon Meats Tea HABITS Exercise? Types? How often? Average 6-8 hrs. sleep? Sleep well? Awaken rested? Enjoy your work? Eat three meals a day?
Please Circle any conditions you have now. Put a P beside any condition you ve had in the past a. General Symptoms Wt. Ht. Fatigue/Weakness Fever Chills Sweats Loss of Weight Anemia Past Blood Transfsions Easy Bruising/Bleeding Lymph Node Swelling Food Allergies Drug Allergies Depression Phobias Insomnia Anxiety Alcohol Abuse Drug Abuse b. Skin Rashes Eczema Psoriasis Dryness/Moisture Oily Hair Changes Nail Changes Temp. Changes Lumps Colour Changes Mole Changes c. Head Headache Dizziness Head Injury Migraines d. Ears Impaired Hearing Earaches Ringing Loss of Balance Dizziness Vertigo Infections Discharge e. Eyes Impaired Vision Glaucoma Cataracts Double Vision Bothered By Sun Eye Pain Itching Redness Tearing Dryness Blurring Discharges f. Mouth & Throat Freq. Sore Throats Freq. Throat Infection Loss of Taste Sore Tongue/Mouth Cankers Gum Problems Stomatitis Dental Cavities/Fillings g. Neck Lumps Pain or Stiffness Enlarged Glands Enlarged Thyroid h. Respiratory Cough Wheezing Asthma Bronchitis Pleurisy Tuberculosis Sputum Difficulty Breathing Emphysema i. Cardiovascular Heart Disease Chest Pain Heart Murmur High Blood Pressure High Cholesterol Purplish/Bluish Skin Palpitations/Fluttering Ankle Swelling Rheumatic Fever j. Gastrointestinal Trouble Swallowing Increase/Decrease Thirst Increase/Decease Appetite Nausea Vomiting Heartburn Indigestion No. of Bowel Mvmnts/Day Constipation Diarrhea Blood in Stool Rectal Bleeding Hemorrhoids Abdominal Pain Hernias Belching/Passing Gas Ulcer Jaundice Liver Disease
k. Urinary Pain With Urination Increased Frequency Urgency Hesitancy Inability to Hold Urine Blood In Urine Frequent Infections Kidney Disease Kidney Stones l. Male Reproductive Hernia Testicular Mass Testicular Pain Low Libido Sexually Active Sexual Difficulties Prostate Disease Venereal Disease Discharge Sores m. Female Reproductive Age Menses Began Length of Cycle Avg. No. Of Days of Menses Last Menstrual Period Irregular Cycles Painful Menses Bleeding Between Menses Excessive Flow P.M.S Low Libido Sexually Active Sexual Difficulties Pain During Intercourse Venereal Disease Birth Control Pregnancies Miscarriages Abortions Difficulty Conceiving Vaginal Discharge Vaginal Itching Vaginal Yeast Infections Menopausal Symptoms Last PAP & Result n. Breast Self Examination Pain/Tenderness Lumps Nipple Discharge Breast feeding o. Musculoskeletal Joint Pain/Stiffness Joint Swelling Arthritis Backache Broken Bones Muscle Spasms/Cramps Muscle Weakness p. Peripheral Vascular Deep Leg Pain Cold Hands/Feet Varicose Veins Thrombophlebitis q: Extremity: Numbness Coldness Swelling Ulcers Tingling r. Neurologic Fainting Seizures/Convulsions Loss of Memory Speech Problems Involuntary Movement Paralysis s. Endocrine Heat Intolerance Cold Intolerance Thyroid Problem Diabetes Hypoglycemia Hormone Therapy t. Infectious Disease Hepatitis A Hepatitis B Hepatitis C HIV AIDS