Dr. Andrea Gri B.Kin, ND Doctor of Naturopathic Medicine Phone: 905-793- 8868 Fax: 905-793- 8957 630 Peter Robertson Blvd, Brampton ON L6R 1T4 ADULT INTAKE FORM Name: (Last) (First) (Preferred Name) Address: City: Postal Code: Home phone number: Email: Preferred form of contact for reminder/follow up calls: Work/Cell: Home number Cell phone Email Other Please specify: Age: Date of Birth: Sex: M F Ethnicity: Occupation: Name of Family Physician: Phone Number of MD: Emergency Contact Name: Relation: Fax: Phone Number: Please list your health concerns in order of importance: 4. 5. Please list all medications (prescription, over- the- counter) and natural products (vitamins, herbs) you are currently taking. Medication/Natural Product Dose/quantity per day Why are you taking this product?
Please list any allergies or sensitivities to medications, food, and the environment. 4. Please list all hospitalizations, surgeries and/or major injuries you have experienced. Description Year Outcome/complications? Please check off any condition(s) you currently or previously have had: Acne Eczema Kidney disease Psoriasis Alcohol abuse Endometriosis Kidney stones Rheumatic fever Anemia Epilepsy Lupus Rubella Angina Gallstones Measles Scarlet fever Anxiety Glaucoma Memory loss Sexually transmitted Arthritis Gout Meningitis infection Asthma Head injury Mental illness Strep throat Autoimmune disease Heart attack Miscarriage Suicide Bleeding disorder Heart disease Mononucleosis Thalassemia Cancer Hemorrhoids Nasal polyps Ulcerative colitis Cervical dysplasia Hepatitis Osteoporosis Urinary tract infections Chicken pox High blood pressure Parasites Whooping cough Chronic bronchitis High cholesterol Pelvic inflammatory Other: Crohn s HIV disease Diabetes Hives Pneumonia Depression HPV Polycystic ovaries Family Health History Mother Father Sister(s) Brother(s) Grandparents Age (or age at death) Health Concerns Personal Health Habits: Height: Weight: Max Weight: When? Smoker? Yes No Amount/day: Years smoked: Year stopped:
Do you do recreational drugs? Yes No Type: Alcohol use? Yes No Type: Frequency: Caffeine use? Yes No Type: Frequency: Please list any dietary restrictions: Do you exercise? Yes No Type: Frequency: How many hours do you sleep per night? Rate your energy level (1 = low, 10 = high): 1 2 3 4 5 6 7 8 9 10 Rate your stress level (1 = low, 10 = high): 1 2 3 4 5 6 7 8 9 10 What are the three major contributors to stress in your life? What do you do to relax? Describe your support network: Describe your living situation: How much time do you spend outdoors per week? Do you wake rested? Yes No Review of Systems: Endocrine 20lbs change in weight poor concentration generally feel hot generally feel cold low blood sugar sluggish after eating excessive sweating excessive hunger excessive thirst Immune chronic infections swollen glands or lymph nodes cold sores frequent antibiotics poor childhood immune health frequent sore throats Neurological/Musculoskeletal numbness tingling paralysis joint pain loss of balance vertigo or dizziness muscle cramps or spasms loss of memory Skin, Hair & Nails rashes itching lumps or abscesses night sweats brittle nails hair loss dry skin warts change in size, shape or colour of a mole or freckle Head, Ears, Eyes, Nose, Throat headache/migraines ringing in the ears impaired hearing itchy ear canal earaches near sighted far sighted poor night vision dry eyes cataracts visual disturbances nose bleeds post nasal drip runny nose hoarseness sore throat jaw pain and clicking teeth grinding
Respiratory System chronic cough cough up blood chronic phlegm wheezing pain while breathing shortness of breath Cardiovascular System chest pain fainting heart palpitations varicose veins easy bleeding or bruising heart murmurs cold hands and feet feel dizzy when stand up quickly pain or heaviness in legs Gastrointestinal System trouble swallowing change in appetite nausea burping blood in stools or on tissue stomach cramps or pain diarrhea or loose stools mucous in stools gas and/or bloating constipation hard stool black stools undigested food in stools heart burn How often do you have a bowel movement? Have you ever travelled to a developing country? If so, please specify where and for how long? Yes No Urinary System pain on urination inability to hold urine wake up to urinate frequent bladder infections must strain to urinate increased frequency Mental/Emotional abuse anxiety or nervousness mood swings irritability panic attacks depression phobias mental illness prolonged sadness or grief Men s Health (if applicable) hernia sexual difficulties low sex drive discharge or sores testicular pain prostate condition testicular mass impotence Are you sexually active? Yes No When was your last prostate exam? Women s Health (if applicable) fibrocystic breasts breast tenderness breast lumps or cysts puckering of skin around nipple nipple discharge Do you perform monthly self breast examinations? When was your last mammogram? Age of first menses Date of last menstrual cycle Length of cycle (days) Yes No Number of pregnancies: Are you currently pregnant? Yes No Are you trying to conceive? Yes No Are you sexually active? Yes No Type of birth control (if any):
vaginal discharge sexual difficulties abortions vaginal itching odour miscarriages vaginal dryness pain during intercourse low sex drive menopausal symptoms abnormal pap test Date of last pap: menstrual pain or cramping missed periods clotting bloating breast tenderness loose stools light flow heavy flow mood swings water retention irregular cycles bleeding between periods bleeding after intercourse low back pain headaches What behaviours or lifestyle habits do you currently engage in that you believe support your health? Is there anything else I should know about your health? How did you hear about us? Thank you for taking the time to complete this form. I look forward to meeting you and working with you towards your health goals. Yours in Health, Dr. Andrea Gri, B.Kin, ND