NATUROPATHY INTAKE FORM - Physiomobility · Dr. Vivian Bizios ND 6 Maginn Mews, Suite 211 Toronto, ON M3C 0G9 Phone: 416-444-4800 | Fax: 416-444-4811 | [email protected]

Dr. Vivian Bizios ND

6 Maginn Mews, Suite 211 Toronto, ON M3C 0G9

Phone: 416-444-4800 | Fax: 416-444-4811

www.physiomobility.com | [email protected]

NATUROPATHY INTAKE FORM

Date: _______________

Last Name: ________________________ First Name: __________________________

Date of Birth (yyyy/mm/dd): _________________ Age: _________________

Marital status: ___________________________

Address: ____________________________________ City: ___________________________

Province: ___________________________________ Postal Code: _____________________

Phone (Home): __________________________________ Cell #: ____________________________

Phone (Work): ___________________________________

Occupation: _________________________________________________________________

Employer: ___________________________________________________________________

Name of Medical Doctor: ____________________________ Phone #: _________________

Who can we thank for referring you to us? _________________________________________

Please list your major complaints in order of importance:

COMPLAINT(S) FOR HOW LONG?

1. ___________________________________________ ___________________________

2. ___________________________________________ ___________________________

3. ___________________________________________ ___________________________

4. ___________________________________________ ___________________________

MEDICATION(S)/SUPPLEMENT(S) FOR HOW LONG?

1. ___________________________________________ ___________________________

2. ___________________________________________ ___________________________

3. ___________________________________________ ___________________________

4. ___________________________________________ ___________________________

Immunizations and reactions, if any? _____________________________________________

Operations or significant injuries, if any? ______________________________________________

FAMILY MEDICAL HISTORY

Mother: _______________________________ Father: _______________________________

Grandparents: __________________________ Siblings: _____________________________

Children: ______________________________



Phone: 416-444-4800 | Fax: 416-444-4811


LIFESTYLE

Please check if you use any of the following:

☐ Alcohol ☐ Eating out times per week ☐ Bottled water

☐ Recreational drugs ☐ Plastic Tupperware for storage ☐ Fast Food

☐ Smoking/vaping ☐ Tap water ☐ Fried Food

☐ Candy/refined sugar ☐ Filtered water ☐ Carbonated beverages

☐ Cold cuts ☐ Coffee, # of cups? __________ ☐ Aluminum pans, Teflon

LIFESTYLE

Exercise? ☐ Yes ☐ No What type? ________________ How Often? __________

How many hours of sleep a night? _________ Do you sleep well? ☐ Yes ☐ No

Awaken rested? ☐ Yes ☐ No

Excessive stress in life? ☐ Yes ☐ No Eat 3 meals a day? ☐ Yes ☐ No

Enjoy work? ☐ Yes ☐ No Wifi/cell phones on during sleep? ☐ Yes ☐ No

Mold in home? ☐ Yes ☐ No Radon tested home? ☐ Yes ☐ No

Use natural cleaning products? ☐ Yes ☐ No Asbestos in home? ☐ Yes ☐ No

Living close to hydro tower/cell tower? ☐ Yes ☐ No

Pesticide use of property? ☐ Yes ☐ No

Please check any condition you have now or have had in the past:

A. General Symptoms Depression Lumps Vertigo

Wt._____ Ht._____ Anxiety Colour Changes Ear Infections

Fatigue & Weakness Alcoholism Mole Changes Discharge from Ear

Fever Cancer C. Head E. Eyes

Chills B. Skin Headache Impaired Vision

Sweats Rashes Dizziness Glaucoma

Loss of Weight Eczema Head Injury Cataracts

Weight Gain Psoriasis Migraines Double Vision

Anemia Acne D. Ears Bothered by Sun

Blood Transfusions Itchy Impaired Hearing Eye Pain

Easy Bruising & Bleeding Dryness Ear Pain Eye Itching

Lymph Node Swelling Oily Ringing Eye Redness

Food Allergies Hair Changes Loss of Balance Tearing

Drug Allergies Temperature Changes Dizziness Eye Dryness



Phone: 416-444-4800 | Fax: 416-444-4811


Blurring Chest Pain & Angina Increased Frequency Cold Intolerance

Eye Discharge Heart Attack Urgency Thyroid Problems

F. Nose & Sinuses Stroke Hesitancy Diabetes

Nose Bleeds Heart Murmur Inability to Hold Urine Hypoglycemia

Allergies High Blood Pressure Blood in Urine Hormone Therapy

Sinus Problems High Cholesterol Frequent Bladder or Q. Infectious Diseases

Congestion Purplish/Bluish Skin Kidney Infections Chicken Pox

Discharges Palpitations & Fluttering Kidney Disease Shingles

Polyps Ankle Swelling Kidney Stones Measles

G. Mouth & Throat Gout M. Musculoskeletal HPV

Frequent Cold & Flu K. Gastrointestinal Joint Pain & Stiffness HIV

Frequent Sore Throat Trouble Swallowing Joint Swelling Warts

Strep Throat Increase/Decrease Thirst Arthritis Parasite (ever?)

Lost of Taste Increase/Decrease

Appetite Back Pain R. Male

Cold Sores Nausea Bone Density Test

(ever?) Hernia

Sore Tongue & Mouth Vomiting N. Arms, Legs, Hands Testicular Mass

Cankers Heartburn & Indigestion & Feet Testicular Pain

Bleeding Gums Belching & Passing Gas Deep Leg Pain Low Libido

Dental Cavities &

Fillings Number of Bowel Cold Hands & Feet Sexually Active

Implants Movements per Day Varicose Veins Sexual Difficulties

Root Canals Constipation Numbness in Hands & Prostate Problems

Tonsils Removed Diarrhea Feet Tingling Discharge

Mono Blood in Stool Coldness Sores

H. Neck Hemorrhoids/Fissures Swelling Rectal Itching

Lumps Abdominal Pain Ulcers Feet S. Women

Pain or Stiffness Hernias Tingling Duration of Menses (days)

Enlarged Lymph Nodes Ulcer O. Neurologic Length of Cycle (days)

Enlarged Thyroid Liver Disease Fainting Irregular Cycles

I. Respiratory Colonoscopy (ever?) Seizures/Convulsions Painful Menses

Cough Diverticulosis

Epilepsy Bleeding Between

Menses

Wheezing Polyps Loss of Memory Excessive Flow

Asthma Appendix Removal Speech Problems P.M.S.

Bronchitis Gall Stones Involuntary Movement Low Libido

Throat Phlegm Gallbladder Removal Paralysis Sexually Active

Breathing Difficulties L. Urinary P. Endocrine Sexual Difficulties

J Cardiovascular Pain Before & During Heat Intolerance Pain During

Intercourse

Heart Disease Urination Cold Intolerance Birth Control



Phone: 416-444-4800 | Fax: 416-444-4811


S. Number of Pregnancies

Breastfeeding

Miscarriages

Abortions

Uterine Fibroids

Uterine Polyps

Ovarian Cysts

Vaginal Discharge

Vaginal Itching

Vaginal Yeast Infections

Genital Herpes

Menopausal Symptoms

Last Breast Exam (Date)

Last Pap Exam (Date)

Patient’s Name: ____________________________________

Patient / Guardian’s Signature: ________________________ Date: _______________

Documents

NATUROPATHY INTAKE FORM - Physiomobility · Dr. Vivian Bizios ND 6 Maginn Mews, Suite 211 Toronto, ON M3C 0G9 Phone: 416-444-4800 | Fax: 416-444-4811 | [email protected]