Dr. Stephanie Liebrecht, BSc., ND Phone: 306-955-2633 Saskatoon Wellness Centre Fax: 306-955-2638 1814 Lorne Ave., Saskatoon, SK S7H 1Y4 Name Date of Birth / / Age (dd/mm/yy) Sex Marital Status Saskatchewan Health # Address Phone: Home Work Cell Emergency Contact Relationship Emergency Contact Phone Number or Primary Physician Clinic Ph Other health care providers you are seeing: Name Specialty Ph Name Specialty Ph Name Specialty Ph How did you hear about our clinic? If referred, please indicate from whom Can we email you? Yes No Email: (Email will only be used by our office to inform you of our clinic events and will not be distributed for any other use) Health Concerns What is your main health concern? How long have you have this concern? Have you had prior/current treatment for this?
List all other health concerns or goals in order of importance 1. 2. 3. 4. Medical History List all current medications and dosages 5. 6. List all current natural health products (vitamins, herbs, homeopathics, etc) and dosages 5. 6. Please indicate any serious conditions, illnesses, injuries, or hospitalizations, and approximate dates when they occurred Do you have any allergies (medicines, environmental, etc) Last time you had blood work done Personal and Family Health History Please rate your general state of health? (circle one) 1 2 3 4 5 6 7 8 9 10 Worst Excellent How would you rate your energy levels? (circle one) 1 2 3 4 5 6 7 8 9 10 Height Current Weight Max Wt Recent wt change? Y/N How much
If female, are you currently pregnant? Y/N/Possible Currently breastfeeding? Y/N Please list any conditions or diseases that affect your family members. If deceased, indicate cause and age at death Mother Father Sister(s) Brother(s) Grandmother(s) Grandfather(s) Consider: allergies, autoimmune disease, cancer, diabetes, depression or other mental illness, heart disease, hyper/hypo thyroid, kidney disease, stroke, osteoporosis Review of Systems Check a þ beside any condition you are presently experiencing, or that you have in the past. If the condition was in the past, mark a P beside the symptom HEAD/NECK Dizziness Neck stiffness Migraine headache Goiter Head injury Neck pain/tension Tension headache Swollen glands EYES/EARS/NOSE Impaired vision Blurring of vision Glaucoma Itchy eyes Eye discharge Eye dryness Light sensitivity Red eyes Cataracts Eye pain Wear glasses or contacts Ear discharge Impaired Hearing Earache Reoccurring ear infections Frequent colds Nose bleeds Loss of smell Nasal congestion MOUTH/THROAT Bleeding gums Hoarseness Loss of taste Dental issues Difficulty swallowing SKIN Acne Eczema Hives Psoriasis Other CARDIOVASCULAR & BLOOD/LYMPHATIC Angina Chest pain Murmurs Swelling of ankles, hands, feet Palpitations Date of last ECG Anemia Easy bleeding/bruising Lymph node swelling Past transfusion
RESPIRATORY Asthma Difficulty breathing Pleurisy Wheezing Bronchitis Emphysema Pneumonia Tuberculosis Cough Pain on breathing Coughing up blood Shortness of breath Last chest X-ray GASTROINTESTINAL Abdominal pain Constipation Hemorrhoids Liver disease Frequent burping Diarrhea Hiatus hernia Nausea Black, tarry stool Food allergies Indigestion Frequently passing gas Blood in stool Heartburn Jaundice Vomiting Change in appetite Gallbladder disease Last colonoscopy EDOCRINE Excessive hunger Excessive thirst Excessive sweating Excessive urination Hormone therapy Hypoglycemia Diabetes Hypothyroid Hyperthyroid Night sweats Heat or Cold intolerance NEUROLOGIC Tremor Numbness or tingling Weakness Speech Paralysis Involuntary movements Seizure/convulsions difficulties Loss of balance Memory changes Loss of coordination MUSCULOSKELETAL Backache Joint pain Muscle pain/cramps Bone pain GENITOURINARY Blood in urine Frequent infections Increased frequency Kidney stones Pain on urination Reduced flow Inability to hold urine STI MALE REPRODUCTIVE Penile discharge Testicular pain/masses Erectile dysfunction Benign Prostate Hyperplasia (BPH) Past PSA levels FEMALE REPRODUCTIVE Age of first menses Length of cycle (days) Length of menses Date of onset of menopause/menopausal symptoms Number of pregnancies Number of live births Are you currently on birth control? Y/N If yes, which one and for how long Heavy menstrual bleeding Menstrual cramping/pain Bleeding between cycles Vaginal discharge Missed periods Pain during intercourse Breast lumps Nipple discharge Infertility Is there anything else that you feel is important that has not been covered?
Appointment Policy There is a $50 cancellation fee for missed appointments or insufficient notice. There are often patients on waiting lists that may need that appointment time. Please give 24 hours notice to cancel a follow up appointment and 3 days notice for an initial consultation. Consent to Treatment Naturopathic doctors assess the whole person, which includes the physical, mental, emotional, and spiritual aspects of a person. Your visit may consist of a thorough case history and a screening physical examination. It is important to inform the doctor of any diseases you may suffer from, and what medications you are taking. If you are pregnant, suspect to be pregnant, or are breast-feeding, please let us know. There may be some slight health risks to treatment by naturopathic medicine. These may include, but are not limited to: allergic reactions to supplements or herbs, aggravation of pre-existing symptoms, bruising, fainting, or injury from acupuncture, puncturing of an organ with acupuncture needles. Results are not guaranteed and not all risks and complications anticipated or explained. You are free to withdraw consent and discontinue treatment at any time. By signing the intake form, you are agreeing to the above terms. Name (print) Signature of Patient or Guardian Date WE ARE A SCENT-FREE CLINIC PLEASE REFRAIN FROM WEARING ANY SCENTED PRODUCTS THE DAY OF YOUR APPOINTMENT. THIS INCLUDES HEAVILY SCENTED LAUNDRY PRODUCTS. THANK YOU FOR YOUR CONSIDERATION.
DIET DIARY Please complete the 5-day diet diary prior to your visit. The diet diary can provide essential information regarding your health, and is a key component to the assessment. Record all food and liquids that you consume which includes breakfast, lunch, supper, snacks, condiments, coffee, water, etc. One of the days must be a weekend day (Sat or Sun). May leave comments/describe symptoms experienced below. Day 1 Breakfast Day 2 Day 3 Day 4 Day 5 Lunch Supper Snacks Comments