102 – 88 Lonsdale Ave, NORTH VANCOUVER, B.C. V7M 2E6 PHONE: (778) 340-1114 FAX: (778) 340-7702

HEALTH APPRAISAL QUESTIONNAIREDR. BRIAN JOHN DAVIES

Patient Information

Name: _______________________________________ Birthday (D/M/Y): ____________ Age: ______ Male: ___ Female:___(First) (Initial) (Last)

Address: ___________________________________________________________________________________________________ (Street) (Apt/Ste #) (City) (Postal Code)

Home phone:________________________ Work/Cell Phone: _______________________ Email: _________________________

Single:___ Married:___ # of Children:_______ Occupation: ____________________________________________________

Parent's name (if a minor): _________________________________________ Referred by: ________________________________

In case of emergency – Name:_____________________________________ Relationship:_________________________________

Contact Number(s):_____________________________________

Current Health Concerns

What are your health concerns in order of appearance

1) ________________________________________________

2)_________________________________________________

3) __________________________________________________

4)___________________________________________________

Medical History

Past illnesses, conditions, and hospitalizations:

___________________________________________________

___________________________________________________

___________________________________________________

Allergies or sensitivities (food, drugs, seasonal, pets, etc.)

___________________________________________________

___________________________________________________

List supplements you are currently taking:

____________________________________________________

____________________________________________________

____________________________________________________

Females: Are you currently pregnant? Yes____ No_____

Date of last physical exam: ______________________________

Family History- Please indicate if a close relative (parent, child, sibling, grandparent) experiences the following:

Allergies Depression

Asthma Other mental illness (specify)

Heart disease Drug abuse

High blood pressure Alcoholism

Cancer Kidney disease

Diabetes Other

Family MD: ________________________________ Address:_______________________________________________________ Phone:________________________

Part I

Circle any of the following medications you are taking or have taken:

Antacids

Antibiotic/Antifungal

Antidepressants

Antidiabetic/lnsulin

Aspirin/Tylenol

Chemotherapy

Cortisone/Anti-inflammatory

Heart Medications

Blood Pressure

Hormones

Laxatives

Lithium

Oral Contraceptives

Radiation

Recreational DrugsSpecify______________________________

Relaxants/Sleeping

Thyroid

Ulcer Medications

Other ___________________

Vaccinations - DPT Chicken pox Flu Hep A/B MMR Polio Hib

Circle if you eat, drink or use:

Alcohol

Candy

Carbonated beverages

Cigarettes

Coffee

Distilled water

Fast food regularly

Fried foods

Lunch meats

Margarine

Refined sugars

Sugar substitutes

Circle if you:

Diet Often Do not exercise regularly

Salt food without tasting

Are under excessive stress

Have mercury or silver fillings

Are exposed to chemicals at work

Are exposed to cigarette smoke

INSTRUCTIONS: Circle the number which best describes your symptoms. If you do not know the answer to a question, leave it blank.

0= Past 1 = Mild 2= Moderate 3 = Severe

Part II

SECTION A:1. Burping ............................................................ 2. Prolonged fullness after meals ........................ 3. Bloating ............................................................ 4. Poor appetite ....................................................5. Stomach upsets easily ...................................... 6. History of constipation ....................................7. Known food allergies .......................................

SECTION B:1. Abdominal cramps ...........................................2. Indigestion 1-3 hours after eating ....................3. Fatigue after eating .......................................... 4. Lower bowel gas ..............................................5. Alternating constipation and diarrhea ..............6. Diarrhea ...........................................................7. Roughage and fiber causes constipation .........8. Mucous in stools ...............................................9. Stool poorly formed .........................................10. Shiny stool ...................................................11. Three or more large bowel movements /day12. Foul smelling stool .......................................13. Dry flaky skin and/or dry brittle hair ..........14. Pain in left side under rib cage .....................15. Acne................................................................16. Food allergies.................................................

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

SECTION C:1. Stomach pains ................................................... 2. Stomach pains just before/after meals ...............3. Dependency on antacids ....................................4. Chronic abdominal pain ..................................... 5. Butterfly sensations in stomach ........................ 6. Difficulty belching ............................................. 7. Stomach pain when emotionally upset ..............8. Sudden, acute indigestion ..................................9. Relief by carbonated beverages ........................ 10. Relief of stomach pain by drinking milk.......... 11. History of ulcer or gastritis .............................12. Current ulcer ..:.................................................13. Black stool when not taking iron supplements

SECTION D:1. Seasonal diarrhea ..............................................2. Frequent and recurrent infections (colds) .........3. Bladder and kidney infections ...........................4. Vaginal yeast infection ....................................5. Abdominal cramps ............................................6. Toe and fingernail fungus .................................7. Alternating diarrhea/constipation ......................8. Constipation ......................................................9. History of antibiotic use ....................................10. Meat eater .........................'.............................. 11. Rapidly failing vision ..................................

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3No YesNo YesNo YesNo YesNo Yes (10)No Yes

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3No YesNo YesNo Yes

Part III

SECTION A:1. Intolerance to greasy foods.................................. 2. Headaches after eating......................................... 3. Light colored stool ...................... ................. ..... 4. Foul smelling stool .............................................. 5. Less than one bowel movement daily ................. 6. Constipation ............................ ........................... 7. Hard stool............................................................. 8. Sour taste in mouth.............................................. 9. Grey colored skin........................ ........................ 10. Yellow in whites of eyes....................................11. Bad breath..........................................................12. Body odor.............................. .............................

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

13. Fatigue and sleepiness after eating...................14. Pain in right side under rib cage.......................15. Painful to pass stool .........................................16. Retain water ....................................................17. Big toe painful ................................................18. Pain radiates along outside of leg ...................19. Dry skin/hair ...................................................20. Red blood in stool ............................................21. Have had jaundice or hepatitis ........................22. High blood cholesterol ....................................23. Is your cholesterol level above 5.20 ................24. Is your triglyceride level above 2.30 ...............

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3No Yes (5)No YesNo Yes (10)No YesNo Yes

Check

Check

Check

Check

Part III (Cont.)

SECTION B:1. Swollen eyes (bulging).........................................2. Strong smelling urine ..........................................3. Thick skin and finger nails ..................................4. Dry skin................................................................5. Sensitive to the cold .............................................6. Cold hands and feet .............................................7. Excessive menstrual bleeding..............................8. Chronic fatigue ....................................................9. Trouble waking up in the morning ...................... 10. Depressed, apathetic .......................................... 11. Low sex drive ....................................................

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

12. Puffy, wrinkly skin .......................................... 13. Sugar causes irritability and mood swings ......14. Premenstrual tension ....................................... 15. Constipation .................................................... 16. Thinning or loss of outside portion of eyebrow 17. Gain weight easily............................................18. Anemia unaffected by iron............................... 19. Axillary (armpit) temperature below 35C........20. Slow reflexes ....................................................21. Infertility ..........................................................

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3No YesNo YesNo YesNo YesNo Yes

Part IV

SECTION A:1. Sensitive to exhaust fumes, smoke, smog, etc .....2. Periodic constipation ...........................................3. Cannot tolerate much exercise ............................4. Depression or rapid mood swings .......................5. Dark circles under the eyes ................................6. Dizziness upon standing .....................................7. Lack of mental alertness .....................................8. Catch colds easily when weather changes ..........9. Difficulty breathing ............................................10. Water retention .................................................11. Eyes sensitive to bright light.............................12. Feel weak and shaky .......................................

SECTION B:1. Inflamed or bleeding gums .................................2. Running nose ......................................................3. Get boils or styes..................................................4. Nosebleeds ..........................................................5. Loss of smell .......................................................6. Throat infections .................................................7. Cold sores, fever blisters .....................................8. Loss of taste..........................................................9. Poor wound healing .............................................10. Hair falls out.......................................................11. Swollen lymph glands........................................12. Ear infection ......................................................13. Hair grows slowly .............................................14. Slow to recover from cold or flu .......................15. Catch colds or flu easily .................................... 16. Bumpy skin on back of arms .............................

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

SECTION C:1. Eczema and psoriasis..........................................2. Asthma/bronchitis ..............................................3. Migraine headaches ............................................4. Entire body aches, painful to touch ....................5. Swollen joints......................................................6. Food sensitivity or allergy...................................7. Certain foods make you sick, depressed, jittery 8. Chronic pain ......................................................9. Painful stomach and/or intestine ........................10. Alternating constipation and diarrhea ..............11. Mucous in throat ...............................................12. Post nasal drip ..................................................13. Discharge from eyes ........................................14. Eyes itch ...........................................................15. Puffiness or dark circles under eyes .................16. Ear discharge or ears stuffed up .......................17. Sinusitis/Rhinitis. .............................................18. Running nose ...................................................19. Breathe through mouth. ...................................20. Swollen tongue ................................................21. Difficulty swallowing ......................................22. Bed wetting .......................................................23. Hyperactivity ...................................................24. Chronic lung congestion...................................35. Use aspirin/tylenol regularly ......................36. Use Cortisone/Prednisone ...............................37. Total body hair loss (Alopecia) ........................

No Yes (10)No Yes (10)No Yes (10)0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3No Yes (5)0 1 2 30 1 2 30 1 2 30 1 2 3No Yes (5)0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

Part V

SECTION A:1. Shortness of breath...............................................2. Chest pain while walking.....................................3. Heaviness in legs .................................................4. Calf muscles cramp while walking .....................5. Heart pounds easily .............................................6. Feel jittery ...........................................................7. Heart misses beats or has extra beats ..................8. Swelling of feet and ankles .................................9. Rapid beating heart..............................................10. Heartburn after eating .......................................11. Pain in left arm ..................................................12. Exhausted with minor exertion .........................13. Do you do aerobic exercise? .............................14. Have you ever exercised regularly?...................15. Bright red nose ..................................................16. At rest heart beats per minute ...........................(under 80 leave blank)

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3Yes NoYes NoNo Yes<80 80-90 90+

SECTION B:1. Cold hands and feet ............................................... 2. Slurred speech .................................................... 3. Headaches .......................................................... 4. Numbness in extremities ................................... 5. Poor concentration ............................................. 6. Ringing in ears ................................................... 7. Ear canal hair ..................................................... 8. Heart attack. ..................................................... 9. Stroke ............................................................... 10. Vertical wrinkle in lower ear lobe ...................

SECTION C:1. Pain when getting up in morning in back of head and neck.......................................................... 2. Dizziness............................................................. 3. Vertigo ................................................................ 4. Fatigue easily ...................................................... 5. Blushing with no apparent cause ....................... 6. Is your blood pressure high?...............................

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3No YesNo Yes (10)No Yes (10)No Yes

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3No Yes (10)

Part VI

SECTION A:1. Dizziness when standing suddenly . . . . . . . . . . . . . . .2. Loss of vision when standing suddenly................ 3. Crave sweets ........................................................4. Headaches relieved by eating sweets or alcohol 5. Feels shaky...............................................................6. Irritable if a meal is missed .................................7. Wake up in middle of night craving sweets ........8. Feel tired or weak if a meal is missed ....................9. Heart palpitations after eating sweets..................... 10. Need to drink coffee to get started .......................11. Impatient, moody, nervous ..................................12. Feel tired 1 to 3 hours after eating ......................13. Poor Memory ...................................................14. Poor concentration ............................................15. Forgetful . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

16. Calmer after eating ..................................

SECTION B:1 Night sweats.......................................................2 Increased thirst ....................................................3 Lowered resistance to infection ......................... 4 Fatigue ................................................................5. Boils and leg sores .............................................6. Lesions, cuts take a long time to heal ................7 Overweight ..........................................................8. Feel more energized after exercise ....................9. Failing eyesight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10. Crave sweets, but eating sweets does not relieve symptoms ...................................................11. Family history of diabetes ................................12. Sugar in urine ...................................................

No Yes

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 3

Part VII

1. Chest pain ...........................................................2. Chronic cough.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. Difficulty breathing ............................................4. Coughing up blood .............................................5. Coughing up phlegm ..........................................6. Pain around ribs ..................................................7. Shortness of breath .............................................8. Rattling mucous when you breathe ....................

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

9. Sensitive to smog ...............................................10. Infections settle in lungs ................................11. Work around people who smoke ....................12 Bronchitis .........................................................13 Exposed to chemicals and radiation ............... .14. Smoker .............................................................What do you smoke? _______________________# per day ____

0 1 2 30 1 2 30 1 2 3No Yes (10)No Yes (5)No Yes (5)

Part VIII

1. Frequent urination ...............................................

2. Frequent bladder infections . .. .. .. .. .. .. .. .. .. .. .. ..

3. Rarely need to urinate ................................

4. Urination when you cough or sneeze ..................

5. Painful/burning when passing urine ...................

6. Difficulty passing urine .......................................

7. Dripping after urination ......................................

8. Can't hold urine ...................................................

9. Rose colored (bloody) urine ................................

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

10. Cloudy urine ....................................................

11. Strong smelling urine ......................................

12. Back or leg pains associated with dripping after urination ................................................

13. History of bladder infections .....................

14. Have used antibiotics to control urinary tract

infections ...............................................................

IF YES. WHEN DID YOU LAST USE THEM?

________________________________________

TREATMENT DURATION _________________

0 1 2 30 1 2 3

0 1 2 3No Yes

No Yes

Part IX (Males Only)

SECTION A:1. Difficulty urinating .............................................. 2. A sense of bladder fullness ..................................3. Increased straining with smaller and smaller ...... amounts of urine passed .......................................... 4. Rose colored (bloody) urine ................................ 5. Pain or burning while urinating ........................... 6. Wake up to urinate at night ................................. 7. Dripping alter urination ...................................... 8. Pain or fatigue in the legs or back .......................9. Lack of sex drive.................................................. 10. Ejaculation causes pain .....................................

SECTION B:1. Difficulty attaining/maintaining an erection

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 3

2. Anxiety or fear of sexual intimacy with women 3. Premature ejaculation ........................................4. Pain/coldness in genital area .............................5. In fe rt i le . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6. Varicose veins on scrotum .................................7. Low sperm count ...............................................

SECTION C:1. Discharge from penis ......................................... 2. Past or present rash on penis .............................. 3. Swollen genitals.................................................. 4. Swelling in groin ............................................... 5. Venereal disease (gonorrhea, syphilis, herpes or other)....................................................................... Do you have V.D. Now?______________

0 1 2 30 1 2 30 1 2 3No Yes (5)No YesNo Yes (5)

0 1 2 30 1 2 30 1 2 30 1 2 3

No Yes (5)Had in past? _____________

Part X (Females Only)

SECTION A: Circle if you experience any of these symptoms within roughly 2 weeks (ovulation) prior to menstruation. (Section A only)1. Monthly weight gain ...........................................2. Depression ..........................................................3. Moodiness/irritability .........................................4. Bloating and swelling .........................................5. Nausea and/or vomiting .......... ........................... 6. Suicidal feeling ................................................... 7. Anxiety ................................................................8. Leg cramps and tenderness .................................9. Asthma attacks ...................................................10. Headaches .........................................................

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3No Yes (10)0 1 2 30 1 2 3No Yes (10)0 1 2 3

11. Easily distracted ...............................................12. Anger ...............................................................13. Tender breasts ..................................................14. Low backache...................................................15. Other ________________________________

SECTION B:1. Vaginal itching ..................................................2. Vaginal discharge ..............................................3. LOW or no sex desire ........................................

4. Dislike for intercourse .......................................5. Missed periods ...................................................6.O ver 15 yrs of age when menstruation began ..

0 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3No Yes No Yes

Part X Section B continued (Females Only)

7. Unable to get pregnant .........................................8. Miscarriages.................. ...............................9. Abortion...............................................................

SECTION C:Check if you experience any of these symptoms during menstruation. (Section C only)1. Low abdominal pain.............................................2. Dull ache radiating to low back or legs ...............3. Increased urinary frequency ................................ 4. Pelvic soreness.......................... .......................... 5. Diarrhea................................................................ 5. Headaches ............................................................ 7. Abdominal bloating ............................................. 8. Menstrual pain ..................................................... 9. Nausea and/or vomiting ...................................... 10. Have to lie down on first 1 or 2 days of period .11. Craving for sweets.............................................. 12. Insomnia ............................................................ 13. Light scanty blood flow .....................................14. Pain and cramps without blood flow .................15. Heavy menstrual bleeding ................................. 16. Anxiety about menstrual cycle .......................... 17. Pain during menses progressively worsening with time .......................................................

SECTION D:1. Vaginal bumps and sores .................................... 2. Pubic area sore.....................................................

No YesNo Yes How many?____No Yes How many?____

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 3

3. Ovarian cysts ......................................................4. Uterine cysts.......................................................5. Pain in ovaries ....................................................6. Breast lumps.......................................................7. Breasts sore to touch ..........................................8. Breasts painful ...................................................9. Water retention...................................................10. Swollen feeling.................................................11. Premenstrual breast pain or discomfort ...........12. Mother used D.E.S. (hormones) while pregnant .................................................................13. Recent pap smear positive................................14. Family history of breast cancer ........................15. Form of birth control: None____ Pill_____ Diaphragm____ Foam_____ Other_____ SECTION E:1. Hot flashes .........................................................2. Night sweats.......................................................3. Hysterectomy ....................................................4. Depression/Mood Swings ........ ........................5. Insomnia ............................................................6. Craving for sweets..............................................7. Heavy bleeding two weeks/month .....................8. Sweating throughout day ...................................9. Dryness of skin, hair, and vagina .......................10. Painful intercourse............................................11. Vaginal pain .....................................................12. Vaginal itching .................................................13. Osteoporosis (Bone loss) .................................

No Yes (10)No Yes (10)0 1 2 3No Yes (10)0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

No YesNo Yes (10)No Yes

0 1 2 30 1 2 3No Yes0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3No Yes

Part XI

SECTION A:1. Pain in fingers.......................................................2. Bones sore/painful ...............................................3. Eat meat................................................................4. Cavities ................................................................5. Arthritis...............................................................6. Drink carbonated beverages/soda .......................7. Gum disease ........................................................8. Bone loss..............................................................9. Calcium deposits .................................................10. Use antacids .......................................................11. Dentures.............................................................12. Bone deformity ..................................................13. Told you have osteoporosis/osteomalacia .........14. Recent bone fracture . .......................................15. Are you post menopause....................................

SECTION B:1. Muscle spasms.........................................2. Tightness in shoulder muscles .............................

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3Yes Amount/week _____LNo YesNo YesNo YesYes # per week ______No YesNo YesNo Yes (10)No YesNo Yes

0 1 2 30 1 2 3

3. Muscle cramps ...................................................4. Pain in arms, hands ............................................5. Leg cramps at night.............................................6. Stiff all over .......................................................7. Stiff in morning ..................................................8. Unable to sit straight...........................................9. Pain in neck and/or shoulders ............................

SECTION C:1. Over flexible joints (double-jointed)..................2. Back pain............................................................3. Swollen knees/elbows .......................................4. Athletic injury....................................................5. Bursitis................................................................6. Tendonitis ..........................................................7. Joint pain.............................................................8. Slipped disc.........................................................9. Herniated disc.....................................................10. Loss in height....................................................11. Injure easily ......................................................

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3No Yes (5)No Yes (10)No YesNo Yes

Part XII

1. Head feels heavy ..................................................2. Light headedness/fainting ....................................1 Loss of balance .....................................................4. Dizziness ..............................................................5. Ringing/buzzing in ears .......................................6.Trembling hands ..................................................7. Loss of feeling in hands and/or feet (toes) ...........8. Exhaustion on slightest effort............. .................9. Limbs feel too heavy to hold up ..........................

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

10. Loss of grip strength ........................................11. Tingling pain sensation.....................................12. 'Convulsions .....................................................13. Incoordination ..................................................14. Nervousness.....................................................15. Accident-prone.................................................15. Loss of muscle tone..........................................17. Need for 10-12 hours sleep/night ....................18. Have had shingles ............................................

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

Part XIII

1. Nightmares ..........................................................2. Can't fall asleep ...................................................3. Intense dreams .....................................................4. Leg cramps/restless leg at night ..........................5. Restless. uneasy sleeper ......................................

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

6. Wake frequently throughout night.....................7. Wake up in the middle of night, can't fall back to sleep ....................................................................8. Sleep walk...........................................................9. Do you have any other symptoms that have not been covered in the questionnaire? ........................

0 1 2 3

No Yes No Yes

No Yes

102-88 LONSDALE AVE, NORTH VANCOUVER, B.C. V7M 2E6 PHONE: (778) 340-1114 FAX: (778) 340-7702

DR. BRIAN JOHN DAVIES ND BSc

INFORMED CONSENT FOR NATUROPATHIC TREATMENT AND EMAIL POLICIES

Consent for Naturopathic treatment is requested to allow for treatment to be recommended and administered. All suggested treatments will be discussed prior to recommendation. If you have any questions about a specific recommendation please advise Dr. Davies of this concern in writing or verbally before starting your treatment. Naturopathic Doctors obtain consent to make sure you are aware of possible side effects and risks of treatment.

Dr. Davies uses the following modalities in his practice: functional medicine, orthomolecular medicine, botanical medicine, pharmaceutical medicine, homeopathy, intravenous therapy, acupuncture, cold light laser therapy, cryotherapy and lifestyle, diet and nutritional counseling.

Even the gentlest of therapies have their complications in certain physiological conditions such as pregnancy and lactation, in very young children, or those taking multiple medications. Some therapies must be used with caution in certain diseases, including, but not limited to diabetes, heart disease, liver disease, and kidney disease. It is very important therefore that you inform Dr. Davies of any of these conditions immediately if applicable. Because each individual may respond differently to treatment, Dr. Davies may not be able to anticipate and explain ALL risks and complications. It is therefore advised to start your treatment slowly, if you are concerned about the possibility of adverse effects.

There are some risks to treatment with naturopathic medicine. These include but are not limited to aggravation of pre-existing symptoms, allergic reactions to supplements, herbs, intravenous and oxygen therapies. Pain, bruising, and injury are possible from acupuncture, fainting or puncturing of an organ with acupuncture needles and bleeding, phlebitis, sepsis, nausea and fainting from venipuncture. Cryotherapy is a minor surgical procedure using high pressured liquid nitrogen. Complications of this treatment may include irritation and discomfort at the site of treatment until tissue healing can occur. Oxygen therapy may cause light-headedness and treatment with nebeulized glutathione may exasperate symptoms of asthma.

I understand that all information provided during my visit is strictly confidential. Information may only be release upon my written request or as required by law. Cases may only be discussed in a clinical setting for the purpose of education. No direct personal information will be revealed about me if my case is discussed.

I acknowledge that I have discussed, will discuss or have the ability to discuss, with Dr. Davies the nature and purpose of any prescribed treatment in general and my treatment in particular. I acknowledge that I may request any research or literature that is available for a specific treatment that is recommended to me.

I consent to the naturopathic treatments offered or recommended to me by Dr. Brian John Davies, ND. I intend this consent to apply to all my present and future naturopathic care.

I have read and understand the above statements regarding potential treatment side-effects. I also understand that there is no guarantee for a specific cure result.

I understand that if I miss an appointment or cancel on short notice (less that 24 hours), I will be charged a fee for the missed appointment. This fee is applied to keep the overall costs of office visits as low as possible for all clients of Westcoast Integrative Health Inc.

EMAIL POLICY AND SERVICE GUARANTEE

Dr Davies will do his best to respond to all emails with as much information as possible. Emails, with respect to questions about recent treatment recommendations and visit information are encouraged, so please send us an email if you have any questions about your treatment or complaints about our service. We want to hear from you and will do everything we can to remedy your concerns.

Based on ethical and legal issues, email responses may not be provided for discussion of test results or new medical concerns, that may arise, that have not been previously discussed and documented in the office. By signing this consent I, also, understand this policy and its intent to avoid harm through electronic transmission of misinformation.

I also consent to receive, via email, electronic copies of test results, invoices, visit recommendations, and other documentation pertaining to my treatment, when necessary.

_____________________________ __________________________________ _____________________________Patient Name Signature of Patient or Guardian Date

(If applicable)

_____________________________ ___________________________________Witness Name Witness Signature