DULT INTAKE FORMthese modalities can be discussed with your Naturopathic Doctor. The Naturopathic...

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ADULTINTAKEFORMFirstName:_______________________LastName:_______________________________

Age:______BirthDate:_____________________________Sex:Male□Female□

StreetAddress:______________________________________________________________

City:______________________Province:_______________PostalCode:____________

Phone:(Home)________________(Work)_____________(Cell)___________________

Wouldyouliketoreceivereminderemailsbefore

E-MailAddress:__________________________________

Wouldyouliketoreceiveourelectronicquarterlynewsletters:YesNo

Occupation:___________________________Employer:____________________________

MaritalStatus:

Single□ Married□ Divorced□Separated□CommonLaw□Widowed□

NumberofChildren:____________

MedicalDoctor’sName:________________________________________________________

MedicalDoctor’sPhoneNumber:________________________

DateoflastPhysicalExamandbloodwork:________________________________

EmergencyContactName:_____________________________________________________

Relation:_____________________________Phone:_____________________________

Howdidyouhearaboutourclinic?______________________________________________

OFFICEUSEONLY:VitalStatistics

Height: Weight: BP: Pulse

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Whatisyourmainreasonforcomingintoday?

______________________________________________________________________

Listotherhealthproblemsthataretroublingyou:

1)___________________________________________Whendiditstart?________

2)___________________________________________Whendiditstart?________

3)___________________________________________Whendiditstart?________

4)___________________________________________Whendiditstart?________

FAMILYHISTORY:

AgeifLiving

AgeatDeath

CauseofDeath HealthConcerns

Mother Father Brother(s) Sister(s) MaternalGrandmother Maternalgrandfather PaternalGrandmother PaternalGrandfather HEALTHHISTORY:

Whatisyourgeneralstateofwellbeingfrom1-10?(10isthehighest)_____

Whatisyourlevelofcommitmenttoyourwellbeing?1-10?(10isthehighest)_____

Onaverage,howwouldyourateyourenergylevelfrom1-10(10isthehighest)______

Pleaselistprevioussurgeries(includedatesifpossible)____________________________

_____________________________________________________________________________

Pleaselistanyallergiestodrugs,plants,foods,animalorother?_________________________

______________________________________________________________________________

Pleaselistcurrentsupplementsand/ormedications:___________________________________

______________________________________________________________________________

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Wereyouvaccinated?Ifso,anyadversereactions?Pleaselist:___________________________

______________________________________________________________________________

Pleasecheckifyouconsume:Alcohol□ArtificialSweeteners□ Coffee/caffeine□ RecreationalDrugs□ SodaPop□ Tobacco□Pleaseindicatewhich,ifany,ofthefollowingyouhavehadeitherNow(N)orinthePast(P):

Allergies EarInfection Malaria Sexualabuse Abscesses Eczema Measles SleepingProblems Alcoholism Emotionalabuse Mentalillness Smallpox Anemia Epilepsy Migraine Strepthroat Arthritis Fainting Miscarriage Stroke Asthma Fatigue Mono Syphilis Balanceissues FungalInfections Mumps Thyroidissues Bladderinfections

Gallstones Numbnessortingling Tonsillitis

Brokenbone Gas/bloating Parasites Tuberculosis Bronchitis Gout PelvicInflammatory

Disease Varicoseveins

Cancer Hayfever Physicalabuse Venerealdisease Chickenpox Headache Pneumonia Visionissues Childabuse Heartdisease Poormemory Warts ChronicSoreThroats

Hemorrhoids Rape Weightissues

Coldhands/feet Hepatitis Rectalbleeding Whoopingcough Depression Herpes Rheumaticfever Worms Diabetes Highblood

pressure Ringinginears Other:

Diphtheria Jaundice Scarletfever

PERSONALHABITS/LIFESTYLE:

Doyouexercise?Y/NWhatforms?_______________________________________________

Doyouhavesleepproblems?Y/NPleasedescribe___________________________________

____________________________________________________________________________

Howmanyhoursofsleepdoyougetpernight?_____Doyouwakerefreshed?Y/N

Doyousweatatnight?Y/NHowisyourgeneralbodytemperature?WarmerCoolerAverage

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Howmuchwaterdoyoudrinkperday?_____Isyourhomedampormoldyatall?Y/N

Doyouworkinthepresenceoftoxicfumesormaterials?Y/NDoyouuseamicrowave?Y/N

FEMALEREPRODUCTION: MALEREPRODUCTION:Ageoffirstperiod______Haveyourperiodsstopped?Y/NAtwhatage?_____Areyourcyclesregular?Y/NArethereanyclots?Y/NAnyspottingorbleedingbetweenyourperiods?Y/NDoyouhaveanypremenstrualsymptoms(PMS)?□ Waterretention□ Breasttenderness□ Irritability□Depression□ Headaches□Anger□ Moodswings□ Crying□Bloating□ Acne□CravingsDoyougetyearlyPAPsmears?Y/NAnyabnormalPAP’s?Y/NBreastlumps?Y/NDoyoudomonthlybreastexaminations?Y/NAreyoucurrentlysexuallyactive?Y/NDoyouusebirthcontrol?Y/NWhattypeofbirthcontrol?_________________________Anyproblemswithsexdrive?Y/N

Doyougetupinthenighttourinate?Y/NAnysoresongenitals?Y/NHaveyoueverhadanyprostateproblems?Y/NEverhadyourprostatechecked?Y/NAnyproblemswithsexdrive?Y/NAnyproblemsgettingand/ormaintaininganerection?Y/NAreyoucurrentlysexuallyactive?Y/NDoyouusebirthcontrol?Y/NWhattype?________________________

OTHER:

Whatlongtermexpectationsdoyouhavefromworkingwithourclinic?__________________

______________________________________________________________________________

Whatexpectationsdoyouhaveofmepersonallyasyourpractitioner?____________

_____________________________________________________________________________

Isthereanyotherinformationyouthinkisimportantformetoknow?____________________

_____________________________________________________________________________

Thank-youforfillinginthisquestionnaire.

Itisavaluabletoolinassessingyourhealthcareneeds.

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Name__________________________________________________________Date________________________

Rateeachofthefollowingsymptomsbaseduponyourtypicalhealthprofilefor:□Past30days□Past48hours

PointScale

0-Neveroralmostneverhavethesymptoms1-Occasionallyhaveit,effectisnotsevere

2-Occasionallyhaveit,effectissevere3-Frequentlyhaveit,effectisnotsevere4-Frequentlyhaveit,effectissevere

Head _____Headaches_____Faintness_____Dizziness_____InsomniaTotal_____

Eyes ______WateryorItchyeyes______Swollen,reddenedorstickyeyelids______Bagsordarkcirclesundereyes______Blurredortunnelvision(doesnotincludenearorfarsightedness)Total_____

Ears ______Itchyears______Earaches,earinfections______Drainagefromear______Ringinginears,hearinglossTotal_____

Nose ______Stuffynose______Sinusproblems______Hayfever______Sneezingattacks______ExcessivemucusformationTotal_____

Mouth/Throat

______Chroniccoughing______Gagging,frequentneedtoclearthroat______Sorethroat,hoarseness,lossofvoice______Swollenordiscolouredtongue,gums,orlips______CanckersoresTotal_____

Skin ______Acne______Hives,rashes,dryskin______Hairloss______Flushing,hotflashes______ExcessivesweatingTotal_____

Heart ______Irregularorskippedheartbeat______Rapidorpoundingheartbeat______ChestpainTotal_____

Lungs ______Chestcongestion______Asthma,bronchitis______Shortnessofbreath______DifficultybreathingTotal_____

DigestiveTract

_____Nausea,vomiting_____Diarrhea_____Constipation_____Bloatedfeeling_____Belching,passinggas_____Heartburn_____Intestinal/StomachpainTotal_____

Joints/Muscles

_____Painorachesinjoints_____Arthritis_____Stiffnessorlimitationofmovement_____Painorachesinmuscles_____FeelingofweaknessortirednessTotal_____

Weight _____Bingeeating/drinking_____Cravingcertainfoods_____Excessiveweight_____Compulsiveeating_____Waterretention_____UnderweightTotal_____

Energy/Activity

_____Fatigue,sluggishness_____Apathy,lethargy_____Hyperactivity_____RestlessnessTotal_____

Mind _____Poormemory_____Confusion,poorcomprehension_____Poorconcentration_____Poorphysicalcoordination_____Difficultymakingdecisions_____Sufferingorstammering_____Slurredspeech_____LearningdisabilitiesTotal_____

Emotions _____Moodswings_____Anxiety,fear,nervousness_____Anger,irritability,aggressiveness_____DepressionTotal_____

Other _____Frequentillness_____Frequentorurgenturination_____GenitalitchordischargeTotal_____

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WelcometoSageNaturopathicClinic!ABOUTUSAtSageNaturopathicClinic,wewantpeopletofeelbetter.Ourvisionistocreateasafespaceforallourpatientsinwhichtheycanstrivefortheiroptimumhealth.Weknowthatintoday’sworld,strivingforoptimumhealthisnoteasy–it’sincrediblychallenging.AtSage,weworktoempowerourpatientstofeelthebesttheycanfeel.Weaimtoeducateourpatientssothattheycanmakethemostinformeddecisionsabouttheircare.INFORMEDCONSENT

NATUROPATHICMEDICINENaturopathicMedicineisthetreatmentandpreventionofdiseasebynaturalmeans.NaturopathicDoctorsassessthewholeperson,takingintoconsiderationthephysical,mental,emotionalandspiritualaspectsoftheindividual.Gentle,noninvasivetechniquesaregenerallyusedinordertostimulatethebody’sinherenthealingcapacity.

INITIALVISIT(S)ANDFEESDuringyourinitialone-hourvisit,yourNaturopathicDoctorwilltakeathoroughcasehistoryandperformabasic/complaint-orientedphysicalexamination.Secondvisitsare45minutesinlengthandincludeBIAtesting,urinesamplingaswellasfollowuponyourconcerns.Subsequentvisitsaretypically30minutesinlength.Asprimarycarephysicians,werecommendbasicscreeninglabexams.Ifyouhavehadlabworkdonewithyourmedicaldoctorinthelast6months,pleasebringacopyoftheseresultswithyoutotheappointment.Ifyouhavenothadanylabworkdonerecently,yourNaturopathicDoctormayprescribecertainlabtestswhichareanadditionalfee.Labfeesvarydependingonwhichtestsarerecommended,formoreinformationpleasecalltheclinicat519-573-6700.Sometherapiesmustbeusedwithcautionincertainconditionsordiseasessuchasdiabetes,heart/liver/kidneydisease,orinyoungchildren,thosetakingmultiplemedicationorpregnancy/lactation.Therefore,itisveryimportantthatyouinformyourNaturopathicDoctorimmediatelyofanydiseaseprocessthatyouaresufferingfrom,aswellas,anymedications(prescriptionorover-thecounter)thatyouaretaking.Ifyouarepregnant,suspectyouarepregnant,oryouarebreastfeeding,pleaseadviseyourNaturopathicdoctorimmediately.ThefeesforNaturopathicMedicineareasfollows:FirstVisit(Aprox.60minutes):$140.00FollowUp(Aprox.45minutes):$100.00ReturnAppointment(Aprox.30minutes):$70.00MiniVisit(Aprox.15minutes):$40.00FullUrineAnalysis:$30.00FeesforNaturopathicMedicinearenotcoveredbyOHIPhowever,mostextendedhealthcareplansprovidesomecoverage.Itisbesttocheckyourindividualplanformoreinformation.

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TREATMENTOPTIONSAnumberofdifferentapproachesmaybeusedthroughoutthecourseoftreatment.YourNaturopathicDoctorwilldiscusswithyouthemostappropriatetreatmentsastheyarerecommended.Treatmentmodalitiesincludedietarymodificationandnutritionalsupplementation,lifestylecounseling,botanicalmedicine,homeopathy,traditionalChinesemedicine&acupuncture,hydrotherapy,andphysicalmedicine.BothourNaturopathicDoctorshaveadditionaltrainingandarecertifiedinparenteraltherapy(IVtherapy)aswellasFirstLineTherapy(adietandlifestylemanagementtherapy).FurtherinformationaboutanyofthesemodalitiescanbediscussedwithyourNaturopathicDoctor.TheNaturopathicDoctormayprescribesupplementsthatcanbepurchasedattheclinicoratotherlocaloptionsi.e.healthfoodstores.Mostinsurancecompaniesdonotcoverthesupplementsthatweprescribeanddispense.PRIVACYPOLICYPrivacyofyourpersonalinformationisanimportantpartofwhatweofferatSageNaturopathicClinic,andprotectingyourpersonalinformationissomethingwetakeveryseriously.Wearecommittedtocollecting,usinganddisclosingyourpersonalinformationresponsibly.

• Onlynecessaryinformationiscollectedaboutyou;• Onlywithyourconsentdoweshareinformationwithothersoutsidetheclinic;• Storage,retentionanddestructionofyourpersonalinformationcomplieswithexistinglegislation

andprivacy• protectionprotocols;• SageNaturopathicClinic’sprivacypolicyconformstoprivacylegislationandstandardsofthe• BoardofDirectorsofDruglessTherapy–Naturopathy.

Personalinformationiscollectedinorderto:

• Assessyourhealth;• Providehealthcare;• Adviseyouoftreatmentoptions;• Establishandmaintaincontactwithyouregardingappointments,invoicingandfollow-upcare;• Sendyoupertinentinformationandmailings;• Facilitateyourinsuranceclaims;• Allowpotentialpurchasers,practicebrokersoradvisorstoconductanauditinpreparationfora

practicesale;• ComplywiththelegalandregulatoryrequirementsoftheDruglessPractitionersAct.

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WAIVER

Bysigningbelow,youhaveagreedthatyouhavereviewedtheaboveinformationthatexplainsthebenefitsandpossiblerisksofNaturopathictreatment.Youunderstandthattheresultsarenotguaranteed.Youdonotexpectthenaturopathicdoctorstobeabletoanticipateandexplainallrisksandcomplications.Withthisknowledge,youvoluntarilyconsenttoNaturopathiccareandintendthisconsentformtocovertheentirecourseoftreatment.Youunderstandthatyouarefreetowithdrawyourconsentatanytime.Youalsoagreethatyouhavereviewedtheaboveinformationthatexplainshowtheclinicwilluseyourpersonalinformation,andthestepsSageNaturopathicClinicistakingtoprotectyourinformation.Youagreethatthecliniccancollect,useanddisclosepersonalinformationassetoutaboveintheinformationabouttheclinic’sprivacypolicies.Signature:_____________________________________Date:__________________________Witness:______________________________________Date:__________________________Printparent/guardian’sname:___________________________________________________(ifunder18yearsofage)SignatureofParent/guardian:____________________________________________________CollaborativeTeam:AtSage,outhealthcareteamworkstoprovidethebestcarepossibleforourpatients.Werecognizethatinsomecases,providingthebesthealthcaremeansutilizingtheskillsofmultiplepractitioners.Insuchcasesallowingforprofessional,opendialogue,regardingyourcase,betweenmembersofyourhealthcareteamatSageNaturopathicCliniccanallowforoptimaltreatmentstrategiesandimprovementinyourhealth.IwelcomeprofessionaldialogueregardingmycasebetweenmembersofmyhealthcareteamatSageNaturopathicClinic:Yes NoSignature:_______________________________