Confidential Patient Intake Form

Personal Information:

Name: ____________________________ Date of Birth: _____________________ Age: _______

Gender: _____ Is this same gender you were born? ____Pronouns: ______ Occupation: ____________

Address (with postal code): ____________________________________________________________

Phone: ___________________________________ Email: ___________________________________

Contacts:

Physician(s) Information: Emergency Contact:Name: _________________________ Name: _________________________Phone: _________________________ Phone: _________________________

Email: _________________________

Medical Information:Health Concerns: (reason for your visit today)(Please note onset of symptoms, duration, & intensity)_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Current Medical History: (Please note any disability under diagnosis)

Diagnosis by GP: ________________________ Diagnosis by GP: _________________________Date of Diagnosis: ________________________ Date of Diagnosis: __________________________

Past Medical History: (please check all the apply) HIV/AIDS Addictions Allergies Amenorrhea Anemia Anorexia Anxiety Appendicitis Arteriosclerosis Asthma Autoimmune Disorder Bleeding Disorder Bronchitis Bulimia Cancer Candidiasis Cataracts Celiac Chicken Pox Chron’s Disease Chronic Fatigue Chronic Pain Depression Diabetes Type 1 Diabetes Type 2 Disordered Eating

Eczema Emphysema Endometriosis Epilepsy Fainting Fibroids Fibromyalgia Gallbladder Problems Goiter Gout Heart Disease Hepatitis A Hepatitis B Hepatitis C Hernia Herpes Simplex Virus High Blood Pressure High Cholesterol HPV Hyperglycemia Hypoglycemia IBS/IBD Jaundice Kidney Disorders Liver Disorders Low Blood Pressure

Lupus Lyme Disease Malaria Measles or Mumps Migraines Mononucleosis Multiple Sclerosis Osteoarthritis Osteoporosis Parkinson’s PCOS Pneumonia Polio Prostate Disorders Psoriasis Psychiatric Disorder Rheumatoid Arthritis Seizures STIs Stomach Ulcers Stroke Thyroid Disorders Tonsillitis Tuberculosis Urinary Tract Infections Other _______________

Family History Addictions Arthritis Asthma Autoimmune Cancer

Diabetes Heart Disease High Blood Pressure Kidney Disease Liver Disease

Neurological Conditions Obesity Psychiatric Stroke Other __________

Allergies:__________________________________________________________________________________ __________________________________________________________________________________

Medications/Supplementation: (Prescribed/over the counter with dosage)__________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Symptoms (Please check all that apply and onset of each)General:

Insomnia Dream-disturbed sleep Excessive sleep Fatigue Dizziness Numbness Poor balance Seizures Premature hair loss

Respiratory Cough Dry Cough Cough with phlegm Cough with blood Shortness of breath Common Cold Excessive Phlegm

Circulatory Cold hands and feet Excessive Bleeding Easy Bruising

Cardiovascular/Chest Chest pains/tightness Palpitations Irregular heartbeat Rapid heart rate Right-sided rib pain

Digestive Nausea Vomiting Diarrhea Loose stools Constipation No daily bowel movement Hemorrhoids Rectal pain Excessive hunger Loss of appetite Weight loss Weight gain Abdominal bloating/gas Belching Acid reflux Hiccups Stomach/abdominal pain Food sensitivities

Musculoskeletal Muscle cramps Body aches Joint pain Swollen joints Paralysis Neck and shoulder tension Hand and arm pain Foot and ankle pain Low back pain Upper back pain

Mental/Emotional Depression Easily stressed Anger Irritability Frequent sighing Fear Grief Worrying Anxiety Forgetfulness Cloudy thinking Obsessive behaviour Lack of motivation Nervous tics Trauma

Head and Face Headache Migraines Jaw pain Facial paralysis Dizziness

Mouth and Throat Sore throat Hoarse voice Difficulty swallowing Mouth ulcers Dry mouth/throat Excessive thirst Lack of thirst Teeth pain/gum problems TMJ

Ears Ringing in the ears Poor hearing Earaches/infection

Eyes Degenerating vision Blurry vision Night blindness Visual spots Red eyes Eye pain

Nose Sinusitis Nasal polyps Post-nasal drip Nose bleeds Nasal discharge Poor sense of smell

Skin Eczema Psoriasis Hives Acne Fungal infections Itchy skin Shingles Dry skin Dandruff Excessive sweating No sweating Night sweats Numbness

Genito-Urinary Urinary tract infections Kidney stones Urinary incontinence Frequent urination Painful urination Dribbling urination Foamy urine Bloody urine Genital pain Genital itching Erectile dysfunction Infertility Seminal emissions Premature ejaculation Decreased libido Painful intercourse Vaginal dryness

Menstruation:

Please indicate your current menstrual cycle status: Menstruating Menopausal Postmenopausal

If applicable, at what age did menopause begin? ___________Please indicate any menopause-related symptoms:

Hot flashes Night sweats

Vaginal dryness Insomnia

Mood changes Depression

If having menstruation cycles, what is your cycle length? ___________(The first day of your menstruation is considered Day 1)

How many days in duration is your menstruation? ___________Please indicate the quality of blood:

Light red Dark red

Bright red Clotted

Other ___________ Unsure

Please indicate the quanity of blood: Heavy flow Normal flow Light flow Unsure

If you experience any cramping, please indicate when? Before menstruation During menstruation After menstruation

Please indicate if you experience any of the following between periods: Vaginal discharge Bleeding Cramps/pain

How would you describe any sensations associated with your cycle? _____________________________________________________________________________________________________________________________

Do you experience breast tenderness? Y / NWhen? ________________________ Where? ________________________

Pregnancy:How many births have you had? _________________Please indicate any pregnancy-related difficulties: ____________________________________________________________________________________________________________________________________________

Are you currently pregnant? Y / NAre you trying to become pregnant? Y / N

Are you currently using contraception? Y / NIf yes, what type and for how long: _____________________________________________________________

Patient Signature: ________________________________

Guardian Signature: ______________________________(If relevant and/or patient is under 19 years old)

Date: ________________