Active-Med Health and Wellness Centre 10650 Leslie St, Unit 7 Richmond Hill, ON L4S0B9 905-237-2012 Patient Intake Form Name (Last, First Middle) Date (DD/MM/YYYY) Date of Birth (DD/MM/YYYY) Preferred Pronoun Address City Province Apt # Postal Code Email Address Telephone Number Cell: Work: Home: Emergency Contact Emergency Contact # Other Healthcare Providers Name Specialty Phone Name Specialty Phone Please rank your health goals in order of importance: 1. 2. 3. 4. Have you been given any prior diagnoses, not listed on left? 5.
Please indicate any areas of pain or tenderness: Page 2 of 6 Intake Form Past Injuries Past Surgeries Past Hospitalizations Please list all current medications or natural health products Do you have any allergies (including medication)? Please indicate How many courses of antibiotics in the past 10 years? Date of last physical exam Date of last bloodwork Current height Current weight Recent weight changes? Y N Are you currently pregnant? Y N Due: Are you currently lactating? Y N Major dental procedures: Braces Filling Root Canals Caps Implants Dentures Are you sexually active? Y N Contraception used, if applicable: Number of children, ages Rate your overall health: Worst that it can be Rate your overall energy: Worst that it can be Pets 1 --- 2 --- 3 --- 4 --- 5 --- 6 --- 7 --- 8 --- 9 --- 10 Best that it can be 1 --- 2 --- 3 --- 4 --- 5 --- 6 --- 7 --- 8 --- 9 --- 10 Best that it can be Rate your stress level: Low to no 1 --- 2 --- 3 --- 4 --- 5 --- 6 --- 7 --- 8 --- 9 --- 10 Unbearable What are the sources of your stress? Describe the emotional climate of your home: What is your occupation? Shift work? Y N Do you enjoy work? Y N Physical activities and recreation (hobbies, passions):
Please answer as it best describes you currently: Page 3 of 6 Intake Form Water intake Y N amount per day glasses Coffee intake Y N amount per day cups form: Tea intake Y N amount per day cups form: Soda/pop Y N amount per day cans form: Alcohol intake Y N amount per week drinks form: Tobacco smoke Y N amount per week cigarettes for how long/quit date: Chew gum Y N amount per day pieces Exercise Y N amount per week hours form: Sleep Y N amount per day hours restful sleep? Y N Work Y N amount per week hours Are you exposed to (check all that apply): tobacco smoke solvents and dyes artificial fragrances Recreational drugs what and how often if quit, for how long/quit date: Women s Health Regular PAPs? Y N date of last PAP: any abnormal PAPs? Y N Breast exams? Y N Self noted changes: last mammogram: Regular periods? Y N age of first period: average cycle length: days, flow: days Heavy periods? Y N Bleeding between periods? Y N Vaginal discharge? Y N PMS? Y N symptoms experienced: Menopause? Y N date of last menstrual period: Pain during intercourse? Y N Vaginal infections: never rarely sometimes frequently Bladder infections: never rarely sometimes frequently Pregnancies: Births: Miscarriages: Abortions: Difficulty conceiving? Y N Men s Health Date of last prostate exam: any abnormal exams? Y N Difficulty urinating completely? Y N Self-testicular exams? Y N Have you ever had any of the following? testicular pain testicular masses sores or ulcers hernias penile discharge erectile dysfunction Notes: Family History of Disease:
Page 4 of 6 Intake Form Active-Med Health and Wellness Centre 10650 Leslie St, Unit 7 Richmond Hill, ON L4S0B9 905-237-2012 Informed Consent Naturopathic doctors assess the whole person, taking into consideration the physical, mental, emotional, and spiritual aspects of the individual. Gentle, non-invasive techniques are used in order to stimulate the body s inherent healing capacity to restore balance to your health. Dr. Vanessa Ling, ND will take a thorough case history and gather information from physical and laboratory assessments. The following modalities may be used: acupuncture, botanical medicine, diet and nutritional counselling, homeopathy, lifestyle counselling, and other soft-tissue manipulations. Please inform your ND immediately of any disease process ongoing currently and any medications or over the counter drugs that you are taking. Please inform your ND if you are pregnant or lactating. As a patient, you will receive information about your diagnosis and treatment, alternatives, effects, costs, benefits, risks, and side effects of your appropriate treatment plan. With any form of medical intervention, there can be some risks to treatment. Examples include but are not limited to: aggravation of pre-existing symptoms, allergic reactions, bruising from acupuncture, and muscle soreness following physical modalities. By signing below, I am indicating that I consent to treatment by my ND, acknowledging the nature, expected benefits, potential side effects/risks, and financial costs of the treatments offered in present and future care. I am free to withdraw my consent and discontinue treatment at any time. I understand that a confidential record will be kept and only released upon my request or as required by law. The information I have provided is complete and inclusive of all health concerns, including the possibility of pregnancy, and all supplements I am taking. I understand that results are not guaranteed. Patient Name (printed) Patient/Guardian Signature Date Dr. Vanessa Ling, ND Naturopathic Doctor Signature Date
Page 5 of 6 Intake Form Active-Med Health and Wellness Centre 10650 Leslie St, Unit 7 Richmond Hill, ON L4S0B9 905-237-2012 Email Consent Form Dr. Vanessa Ling, Naturopathic Doctor may use email to communicate with their patients. This information may be confidential and personal in nature. Although careful precautions will be taken to keep these emails confidential, email messages in general are not encrypted and may exist indefinitely. The security of messages sent outside of the clinic cannot be guaranteed. Dr. Vanessa Ling, Naturopathic Doctor cannot guarantee that your email will be received, read, or responded to within any particular period of time. YOU MUST NOT COMMUNICATE WITH THE CLINIC VIA EMAIL FOR MEDICAL EMERGENCIES OR OTHER TIME-SENSITIVE MATTERS. The main advantage of email communication is convenience, particularly when scheduling appointments and receiving timely information regarding your care and test results. By signing below, I agree that my email may be used to send personal health information to me: Patient Name (printed) Patient/Guardian Signature Date Patient Email
Review of Systems Page 6 of 6 Intake Form Please check (and circle applicable terms) if you have previously (P) or are currently (C) experiencing any of the following: P C P C P C Skin Respiratory Endocrine rashes / hives / itching asthma cold / heat intolerance acne / boils / lumps pneumonia hypothyroidism dry / oily skin wheezing hyperthyroidism hair / nail changes tuberculosis hypoglycemia bruises easily emphysema diabetes ulcers / cancer chronic cough hormone replacement excessive sweating difficulty breathing colour changes pain on breathing Musculoskeletal fever / chills bronchitis bone fractures warts spitting / coughing up blood joint pain / stiffness change in moles spitting / coughing up phlegm shoulder pain night sweats spinal curvature sensitive skin Cardiovascular fibromyalgia eczema heart disease spinal cord injury psoriasis rheumatic fever muscle weakness heart attack back pain Head anemia foot trouble headache phlebitis poor posture jaw pain high blood pressure tendonitis migraines angina / chest pain gout head injury irregular heart beat muscle spasms / cramps dizziness hardening of arteries arthritis loss of consciousness varicose veins swollen joints high cholesterol osteoporosis EENT heart murmur bursitis impaired vision pacemaker stiff neck sensitivity to light ankle swelling floaters cold hands / feet Neurological ringing in ears fainting sinus problem Gastrointestinal loss of memory gum problem gas (flatulence) involuntary movement tonsillitis abdominal cramps convulsions cataracts abdominal bloating numbness / tingling eye pain / itching hepatitis loss of balance corrective lenses colitis speech problems ear pain / discharge blood in stool paralysis frequent colds indigestion epilepsy nasal obstruction nausea dental decay constipation Urinary hoarseness hemorrhoids pain on urination glaucoma gallbladder problems blood in urine tearing / dryness Crohn's disease increased frequency impaired hearing heartburn incontinence ear infection excessive thirst pus in urine hay fever vomiting frequency at night frequent sore throats diarrhea urgency / hesitancy loss of taste / smell jaundice kidney stones enlarged glands diverticulitis frequent infections trouble swallowing excess hunger