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1281 Shppers Rw NATUROPATHIC ADULT INTAKE Naturpathic medical care requires a healthy relatinship between prvider and patient. Yur respnses t the fllwing questins will significantly cntribute t yur dctr's understanding f yu and yur health histry. Please cmplete in as much detail as yu feel is relevant and t the degree that yu are cmfrtable. Thank yu! PERSONAL INFORMATION: Date f Birth: Age: Address: City: Prvince: Pstal Cde: Phne #: (H): (Cell): (W): Okay t leave a message re: appintments? (Please circle) YES / NO Email: Occupatin: Hurs per week: Emplyer: Emergency cntact: Relatin: Phne: MSP Care Card #: Hw did yu hear abut ur clinic? (Please check bx) Current patient f CR Chirpractic Medical Dctr/Specialist (please prvide name): Other Health Care Prvider (please prvide name): CR Chirpractic Staff What expectatins d yu have f me as yur physician? What expectatins d yu have frm this first visit t ur clinic? Extended Cverage: YES / NO Scial Media (Facebk, Twitter, etc) Advertising Website (campbellriverchirpractic.ca OR vitalrtswellness.ca) Infrmatin Sessin Other: What is yur main reasn fr seeking naturpathic care? If yu have a specific health cnditin, please describe it in detail. (Eg. When was the first time yu nticed yur cnditin and describe any factrs that yu suspect may have played a rle in its nset and cntinuatin.) Please list any ther health cncerns (physical, emtinal r mental) in rder f imprtance: Current general practitiner - MD: Phne: Clinic: List ther health prfessinals and their clinic name yu are seeing and include their area f practice (Eg. Massage). Practitiner Practitiner Type: Cntact #: Practitiner Practitiner Type: Cntact #: Practitiner Practitiner Type: Cntact #: 1

1281 Shppers Rw Date f Birth: Hw d yu rate yur verall health? POOR FAIR AVERAGE GOOD EXCELLENT Hw d yu rate yur verall energy? POOR FAIR AVERAGE GOOD EXCELLENT Current Weight: Height: Wt. 1 yr ag: Max. adult Wt.: Min. adult Wt: MEDICATIONS: Please list all current medicatins (prescriptin and ver-the cunter): Medicatin Dse/day Hw lng? 1. 2. 3. 4. Apprximately hw many times have yu taken antibitics? Have yu had an adverse reactin t a medicatin? NO/YES ALLERGIES: List all (t medicatins, pllens, fds, animals etc.): List the Medicatin: OVER THE COUNTER REMEDIES/SUPPLEMENTS: List all remedies/supplements (herbal, vitamin/mineral, nutritinal, hmepathic etc.) yu are taking: 1. 5. 2. 6. 3. 7. 4. 8. CHILDHOOD MEDICAL HISTORY: Please CIRCLE if yu have had any f the fllwing childhd illnesses: Asthma Measles Rheumatic fever Chicken px Mumps Diptheria Scarlet fever Mn (hw lng? ) Tuberculsis Eczema Pli Whping cugh Frequent ear infectins/clds Rubella (German measles) Other: IMMUNIZATIONS: (CIRCLE all that yu have had) DPT HAEMOPHILUS INFLUENZA B HEPATITIS A HEPATITIS B MMR TETANUS CHICKEN POX SMALLPOX POLIO FLU SHOT OTHER: Any adverse reactins t a vaccinatin? Briefly describe if applicable: 2

1281 Shppers Rw Date f Birth: Please list (with apprximate dates) any serius illnesses, injuries, surgeries r hspitalizatins. FAMILY HISTORY: Please indicate whether any f yur family members have, r have had, the fllwing: Cnditin Relative Cnditin Relative Alchlism Diabetes Allergies Drug abuse Alzheimer s disease Heart cnditin Arthritis High bld pressure Asthma Kidney disease Cancer (indicate type) Osteprsis Depressin Strke Other mental illness Suicide Bleeding disrders Infertility Glaucma Thyrid Cnditins LIFESTYLE FACTORS Any current dietary restrictins? (vegan, vegetarian, etc.) Hw much water d yu drink in a day? On average, hw many hurs f sleep d yu get each night? D yu exercise? Y / N What type(s) f exercise and what frequency? Gd Quality? Y/N What d yu enjy fr recreatin and relaxatin? D yu have a religius r spiritual practice yu wuld like us t knw abut? D yu currently cnsume any f the fllwing? (Indicate hw ften, hw much and fr hw lng) Alchl: Tbacc: Cffee: Sft drinks: Black tea: Marijuana: Laxatives: Other: Are yu frequently expsed t animals? Y / N Type: Expsed t txins r hazards at hme? Y / N List: Expsed t txins r hazards at wrk? Y / N List: 3

Relatinship status: Date f Birth: Number f children + ages: 1) 2) 3) 4) 5) What is the emtinal climate f yur hme? 1281 Shppers Rw Rate yur current stress level (CIRCLE): LOW AVERAGE HIGH UNBEARABLE Which factrs mst cntribute t yur stress? (CIRCLE) HEALTH WORK MONEY FAMILY RELATIONSHIP OTHER: MALE REPRODUCTION D yu have regular annual health screening tests? (bld wrk, prstate examinatin) Y / N Date f last prstate examinatin? (mnth/yr) / Are yu sexually active? Y / N Have yu been sexually active in the past? Y / N Current frms f cntraceptin? Any difficulty with urinatin? Y / N Hw ften d yu urinate at night? Have yu had any f the fllwing? (CIRCLE) TESTICULAR PAIN HERNIA STIs DISCHARGE SKIN LESIONS D yu have any sexual prblems r cncerns? Y / N If yes, please explain: FEMALE REPRODUCTION Are yu currently pregnant? Y / N D yu get regular PAP smears? Y / N Date f last PAP? (mnth/year) / Have yu ever had an abnrmal PAP? Y / N What was the utcme? Age f first perid? Is yur perid regular? Y / N Length f mnthly cycle (eg 28,32): days Average # days f perid r flw (3,5,7): D yu experience PMS? Y / N D yu have sptting/bleeding between perids? Y / N Please circle relevant PMS symptms: BLOATING BREAST TENDERNESS IRRITABILITY DEPRESSION HEADACHES MOOD SWINGS FOOD CRAVINGS OTHER: Are yu menpausal? Y / N If yes, age f last perid: Are yu sexually active? Y / N Have yu been sexually active in the past? Y / N Current frms f cntraceptin: Have yu ever had a sexually transmitted infectin? Y / N Number f pregnancies: Births: Miscarriages: Abrtins: Have yu ever had any f the fllwing cncerning yur breasts? (CIRCLE) PAIN LUMPS INFECTIONS CYSTS NIPPLE DISCHARGE D yu experience vaginal infectins? NEVER RARELY FREQUENTLY D yu experience bladder infectins? NEVER RARELY FREQUENTLY D yu have any sexual prblems r cncerns? Y / N If yes, please explain: 4

Date f Birth: 1281 Shppers Rw REVIEW OF SYSTEMS Please CIRCLE if yu are currently experiencing any f the fllwing symptms OR if yu have experienced any f these symptms befre write a P fr Past. GENERAL SYMPTOMS: EARS/EYES/NOSE/THROAT CARDIOVASCULAR: Headache Dental decay Lw Bld Pressure Head injury Gum disrder High Bld Pressure Fever Enlarged thyrid Previus Strke Chills Tnsillitis Hardening Arteries Sweats Sre Thrat Swelling f Ankles Dizziness Harseness Pr Circulatin Fainting Enlarged Glands Paralytic Strke Lss f Sleep Glaucma Irregular Heart Beat Fatigue Failing visin Shrtness f Breath Nervusness/Anxiety Cataracts Chest Pain Lss f Weight Eye Pain Numbness/pain (extremeties) Ear discharge GASTROINTESTINAL: Allergies Deafness Blating Cnvulsins Hay Fever Excessive thirst Depressin Mercury dental fillings Excessive hunger Ear ache Reflux SKIN: Nasal Discharge Eating Disrder Change in mle(s) Nse bleeds Belching Hives / allergic reactins Nasal bstructin Gas (flatulence) Acne / skin eruptins Sinus Infectin Nausea Itching (ears, skin, rectum) Vmiting Bruising easily MUSCLE & JOINT Vmiting f bld Dryness Fracture/dislcatin Abdminal Cramps Bils Stiff neck Cnstipatin Varicse veins Back pain Diarrhea Sensitive skin Muscle weakness Hemrrhids Swllen jints Liver prblems KIDNEYS/REPRODUCTIVE Painful tailbne Jaundice Prstate inflammatin Ft prblems Gallbladder issues Genital lesins Pain in shulders Irritable Bwel syndrme Inability t cntrl urine Hernia Crhn s Disease Frequent urinatin Spinal curvature Ulcerative Clitis Painful urinatin Pr psture Bld in urine Arthritis RESPIRATORY Pus in urine Asthma Kidney infectin Difficulty breathing Kidney stnes Chrnic cugh Erectile dysfunctin Spitting up phlegm Infertility Spitting up bld Thank yu fr taking the time t fill this ut cmpletely. 5

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