PLEASE NOTE: WE ARE A FRAGRANCE FREE BUILDING. *(Please circle answer where ever there is a multiple question.)

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1 Dr. Stephen Maltais ND, Naturopathic Doctor 88 Dover Mills Road, Port Dover, ON. N0A 1N1 Phone: (519) 583-1234 E-mail: docmaltais@kwic.com www.dovernaturoapth.com INTAKE FORM FEMALE (16 years of age or older) PLEASE NOTE: WE ARE A FRAGRANCE FREE BUILDING *(Please circle answer where ever there is a multiple question.) TODAY S DATE: NAME: AGE: DATE OF BIRTH: ADDRESS: CITY POSTAL CODE: EMAIL ADDRESS: HOME PHONE: ( ) WORK PHONE: ( ) MARITAL STATUS: S M D W Sep NUMBER OF CHILDREN: REFERRED BY: OCCUPATION: EMPLOYER: EMPLOYMENT STATUS: Full-Time Part-Time School Retired Unemployed Self-Employed Other LIVING SITUATION: Alone Spouse Partner Friend(s) Parent(s) NAME & AGES OF THOSE LIVING WITH YOU: PETS: NAME OF Partner/Spouse/Parent: OCCUPATION: IN CASE OF EMERGENCY NOTIFY: PHONE NO: RELIGIOUS/SPIRITUAL PREFERENCES, if any: EDUCATIONAL BACKGROUND: HOW DID YOU HEAR ABOUT THE CLINIC? Do you have extended healthcare benefits?

2 Please list the major complaints in order of importance for you: 1. Complaint Since Cause 2. 3. 4. MEDICAL STATUS General Health: Excellent Good Fair Poor What medications are you currently taking? What was the date of your last full medical examination? The date(s) of any blood test(s) you have had done: List any vitamins, supplements, homeopathic or herbal medications you are taking: What other treatments are you currently following? Have you ever had your cholesterol level checked? Date(s) Result(s) Have you ever had a mammogram? Date(s) Result(s) Do you do self-breast exams? Health History (Please circle if you Had or Have any of the following): Abscesses Chicken pox Fungal infections Kidney disease Rheumatic fever Syphilis Alcoholism Chronic fatigue Gallstones Leukemia Rubella Tonsillitis Allergies Circulatory problems Glaucoma Liver disease Scarlet fever Tuberculosis Amnesia Cold sores Goiter Migraines Senility Typhoid fever Anemia Colitis Gonorrhea Miscarriage Serious injury Venereal warts Anorexia Colon disease Gout Mononucleosis Sexual abuse Warts Arthritis Compulsive eating Hay fever Mumps Sinusitis Whooping cough Asthma Depression Heart disease Parasites/worms Skin disease Yellow fever Autoimmune Diabetes Hepatitis Peritonitis Strept throat Bleeding disorders Eczema Herpes genitalia Pelvic inflammation Stroke Cancer Emphysema Hypertension Pleurisy Sunstroke Candida (Yeast) Epilepsy Hypoglycemia Pneumonia Other Past Medical Conditions High Blood Pressure Stroke Varicose Veins Phlebitis Clotting defects Bleeding tendencies Blood transfusion Diabetes Kidney trouble Rheumatic fever Jaundice/Hepatitis Epilepsy Arthritis Colitis Asthma Chronic Fatigue Syndrome/Eptein Barr Childhood diseases: German Measles Chicken Pox Other: Heart Trouble: Fractures: Cancer Eating Disorder Other major conditions? Never well since an illness or infection (What?) Had a chronic/reoccurring infection or problem (What?)

3 HABITS Dietary preferences/restrictions: Sample of day s menu: Breakfast: Lunch: Dinner: Routine physical exercise? Type of exercise: For how many minuets? How often? Tobacco use (how much): Previously? How much? How long? Alcohol use (how much): How often? Caffeine use (how much): Mood altering substance use (e.g. marijuana, cocaine) past & present? STRESSES Stresses (family, work, self, etc.): _ Have you had any Hospitalization, Surgeries, etc. List what type they were, when they occurred and if there were any complications. Diagnosis/Operation Hospitalization/Date Doctor Complications PREGNANCIES (including miscarriages and abortions) Dates How Far Along? Sex Weight Problems? GYNECOLOGICAL HISTORY Date last period began: Date of last pelvic exam: Date prior period began? Date of last Pap smear: Was your last Pap smear normal? Age at first period: Did you ever have an abnormal Pap? When: Results: Treatment: Are you sexually active? Do you have intercourse? Do you practice safe sex? Are you trying to get pregnant? How long? Current birth control method: How long? Problems with current birth control method? Past birth control methods: Normally (not on pills), the number of days from the start of one period to the start of the next? Number days of flow: Amount of bleeding: Amount of cramps: Premenstrual symptoms: Starting when? Any current changes in your normal pattern? Any bleeding between periods? When? Any unusual pelvic pain, pressure, or fullness? When? Describe: Any unusual vaginal discharge or itching? Describe: How long? Past treatment: Any sexual concerns to discuss? Any past history of tubal infection? When? Any past history of sexually transmitted disease? What & When: Any history of DES exposure (DES was a drug taken by mothers during pregnancy to prevent miscarriage)? Other:

4 CURRENT/RECENT HEALTH CARE PROVIDER(S) Name Date(s) Care Provided DENTAL HISTORY Name of Dentist Address: Phone Number Date of last dental check-up for what? Does your child have: Root Canals how many? Cavities how many? Gum Disease Age of child for first tooth Age of child for permanent teeth Which of the following ailments, or any other major ailments, have affected your relatives? Please circle: Alcoholism Asthma Diabetes Gout Insanity Skin disease Allergies Cancer Epilepsy Hay fever Paralysis Syphilis Arthritis Depression Gonorrhea Heart disease Pneumonia Tuberculosis Other: Relatives Mother Father Brothers Sisters Children Maternal Grandmother Maternal Grandfather Maternal Aunts/Uncles Paternal Grandmother Paternal Grandfather Paternal Aunts/Uncles Age if alive Age at death Ailments REVIEW OF SYSTEMS Circle any symptoms of present significance. GENERAL PHYSICAL Fever or Chills Hot Flashes Unusual Hair Growth Skin Eruptions Weight Change ABDOMOMEN Bloating Heartburn/Indigestion Cramps or pain Nausea or Vomiting Diarrhea Constipation Change in bowel habits Bloody or tarry stools Hemorrhoids Flatulence HEAD Headaches Dizziness Visual defects Hearing defects Sinus trouble Fainting spells BLADDER Frequent urination Painful urination Blood in urine Inability to hold urine Inability to empty bladder Need to get up in the night to urinate CHEST Chest pain Shortness of breath Heart murmur Mitral valve prolapse Palpitations Chronic cough Coughing up blood Wheezing

5 BREASTS Lumps Bleeding Discharge Tenderness COMMENTS OR OTHER CONCERNS: What are your goals and/or expectations of visiting a Naturopathic Doctor? What changes have been made to improve your quality of life? * Please be advised that a cancellation fee of $50 applies to appointments missed without 24 hours notice. (Weather permissible)

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