Naturopathic Medicine Intake Form Adults (16+)

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Transcription:

Naturopathic Medicine Intake Form Adults (16+) Name: Date of birth: Gender: Address: City: Postal Code: Home Phone: Mobile/Work: Email: Marital status: Spouse/Partner s name: Emergency Contact: Phone Number: How did you hear about Dr. Jones? Describe your general state of health: Excellent Good Fair Poor Please list your chief health concerns and goals for treatment: If not included in the above list, please tell me about any current or past medical conditions, serious illnesses, injuries or hospitalizations with approximate dates:

Family physician: City: Date of last physical and/or blood work: Other practitioners you see: Current medications including prescription or over the counter drugs & natural health products: Medication Why you take it Dose Taken since How many times have you taken antibiotics in the last year? List any drug allergies: Family History Mother Father Siblings Grandparents Children

Lifestyle Describe the level of stress in your life: Minimal Moderate Significant Unbearable List the main stressors: Have you ever received counselling or psychotherapy? YES NO Do you have emotionally supportive friends or family members? YES NO How do you cope with stress? Rate your energy level (0-10 with 10 being excellent): 0 1 2 3 4 5 6 7 8 9 10 Do you have difficulty sleeping? YES NO Do you wake rested? YES NO How many hours do you sleep? Do you work shift work? YES NO Occupation: Do you enjoy it? When and where was your last vacation? Hobbies and interests: Who do you live with? Do you have any children? YES NO How old are they? Do you have any pets? Describe your physical activity/exercise habits (what and how often): Are you happy with your weight, body composition and level of physical fitness? YES NO Weight: Height: Fitness goals:

Describe what you eat in a typical day: Meal Time of day What and how much Breakfast Snack Lunch Snack Dinner Dessert/night time eating? Describe your consumption of the following: How much? How often? Coffee or Black Tea Soft drinks Artificial sweeteners Candy/Sweets/Sugar Alcohol Smoking Recreational drugs Pain killers Antacids Diet pills Laxatives

Review of body systems - Please circle all that apply: General: Eyes: bad breath Hematological: unexplained weight loss unexplained weight gain change in appetite fatigue fever or chills night sweats trouble sleeping Skin: rashes itching burning dryness hair or nail changes mole changes Head & neck: head injury headache migraines neck pain/stiffness lumps/masses thyroid problems visual changes eye pain redness double vision blurry vision flashing lights cataracts glaucoma Ears, nose, throat, mouth: hearing loss ringing in ears earache vertigo sinus congestion sinus pain nasal discharge nosebleeds hay fever frequent sore throat hoarseness sore tongue dry mouth thrush non-healing sores dental infections bleeding gums cold sores Cardiovascular: chest pain tightness in chest heart palpitations dizziness fainting spells shortness of breath with activity and/or waking you up difficulty breathing if lying down ankle swelling leg cramping calf pain with walking Immunologic: hives allergies infections easy bruising/ bleeding anemia swollen glands Endocrine: hair loss heat intolerance cold intolerance excessive sweating excessive thirst change in appetite Respiratory: dry cough wet cough productive cough coughing up blood shortness of breath wheezing painful breathing Gastrointestinal: difficult/painful swallowing heartburn/reflux

nausea/vomiting Females: Males: back pain changes in bowel habits # bowel movements per day: constipation diarrhea yellow eyes/skin abdominal pain bloating/gas black/bloody stool rectal bleeding hemorrhoids incontinence Urinary: pain burning frequency urgency leaking incontinence blood in urine dribbling decreased flow incomplete voiding bladder infections sexual orientation: age of first period: irregular periods painful periods heavy bleeding PMS fertility concerns # pregnancies: # childbirths: currently pregnant breastfeeding menopause hot flashes vaginal dryness pain with sex loss of sex drive abnormal PAP(s) vaginal discharge vaginal itching masses sores STI(s) sexual orientation: erectile dysfunction premature ejaculation penile discharge pain with sex loss of sex drive hernia prostate issues masses sores STI(s) Breasts: breast lumps/ masses nipple discharge breast pain dimples/skin changes Musculoskeletal: physical trauma muscle pain/ stiffness cramping restless legs joint pain joint stiffness joint swelling joint redness Neurological: dizziness fainting seizures weakness numbness tingling tremor Psychiatric: stress mood swings memory loss nervousness anxiety depression thought of self-harm thoughts of suicide eating disorder substance abuse trauma/grief

What To Expect: Naturopathic medicine is a system of primary healthcare integrating standard medical diagnostics with complementary and alternative therapies. A naturopathic doctor (ND) considers how diet, lifestyle, the environment, personal relationships and mental/emotional factors influence your health and well-being. During your initial consultation the ND will conduct a thorough assessment of your health concerns and answer your questions. Your ND will communicate her findings, suggest lab testing when relevant and recommend a course of treatment. She will explain the anticipated benefits, possible risks, side effects and associated costs of her recommended course of action. Naturopathic therapies are generally safe and well tolerated. As with any medical intervention results are not guaranteed and there may be health risks associated with certain treatments including but not limited to aggravation of pre-existing symptoms and allergic reactions. In order to ensure safety it s essential that you inform your ND of all health conditions and symptoms you re experiencing as well as all prescription and over the counter drugs and natural products you re taking. Please notify your ND if your condition or medication use changes during the course of therapy. Privacy Policy: All personal and medical information is kept strictly confidential and will not be released to anyone without your written consent. You may request a copy of your records at any time for an administrative fee of $0.25 per page. Booking and Payment: 1) Please provide 24 hours notice if you need to cancel or reschedule appointments. 2) Any discussion about your healthcare and treatment must take place during a scheduled visit. Please reserve email and text messaging with the doctor for scheduling purposes only. If you have a question or a new concern arises, please schedule an appointment. 3) Please allow up to 90 minutes for your initial consultation and 60 minutes for your second visit. 4) Follow up visits vary in length depending on the time needed to address your health concerns and monitor response to treatment. To ensure the best possible care, patients with complex and/or multiple health concerns are asked to schedule longer visits. Should your visit require less time than what was scheduled, the fee will be adjusted to reflect the actual visit length as per enclosed fee schedule. 5) Fee Schedule: Visit length Fee Initial visit - 90 minutes $180 Second or complex visit - 60 minutes $130 Follow up - 45 minutes $110 Follow up - 30 minutes $80 Phone consultation - up to 20 minutes $50 6) Naturopathic medicine is not covered by OHIP. Payment is due in full at the conclusion of each visit and official receipts are provided. The clinic accepts payment by Debit, Visa and MasterCard.

Acknowledgement of Informed Consent By signing below I acknowledge that I have read and understand what to expect including the important policies and fees outlined on page 7. I provide informed consent to receive naturopathic care, including assessment, treatment and follow up from Dr. Aranka Jones ND. I understand that I will have the opportunity to discuss the anticipated benefits and associated risks of the recommended assessment and treatment. I understand that I may withdraw my consent at any time. Patient name: Signature: Date signed (YYYY/MM/DD):

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