These forms are for patients that have made appointments. If you have not made an appointment please call us at 905-684-4934. To fill out the New Patient Form please use a computer. Mozilla Firefox, Ipads and Mobile devices will not work.
Usual First Name:
Title:
Mr
Mrs
Miss
Ms
First Name:
*
Middle
Surname:
*
Address:
*
City:
*
Prov/State:
*
PC/Zip:
Home Phone Number:
Business Phone Number:
Occupation:
Education:
HS Diploma
College Diploma
Bachelor’s Degree
Master’s
Doctoral Degree
Birth Date:
*
-
Month
-
Day
Year
Date
Age:
*
Status:
*
S
M
D
W
Number of children:
*
None
1
2
3
4
5
6
7
8
9
Years of Birth:
*
Ethnic background?:
Speak any other languages?
E-mail address:
*
If 16 or under father and/or mother’s name:
Referred by:
Yellow Pages ad
Website
Friend/Colleague
Family Member
Health Food store
Medical Doctor
Dentist
Chiropractor
Buffalo Healthy Living
In Good Health
Niagara Gazette
Vitality Magazine
Facebook Ad
Google Ad
when does your insurance renew each year?
Have you ever been treated by a Naturopath?:
*
Yes
No
When?:
*
-
Month
-
Day
Year
Date
By whom?:
*
Receive health insurance through work?:
*
Yes
No
How much per year?:
*
Who is your health insurance provider?:
when does your insurance renew each year?
Who is your employer?:
***APPOINTMENTS***
48 hours notice
is also required for
ALL
cancellations of appointments.
A $40 fee
will be charged for a missed appointment, if no prior notice is given to our office. Should you fail to attend your initial appointment with us without notice you will be billed up to
50%
of the initial visit fee.
By notifying us of your change in schedule, you allow someone else to receive the vital treatment they need.
Please take a few minutes to answer the questions in ink on the following pages. All of your medical information is of value to us. If your condition is not well covered by the questions that follow, please feel free to write it in.
Please read the enclosed fee schedule.
I have read the fee schedule and asked questions to clarify anything that was not clear to me. I completely understand what I am signing and agree to abide by the clinic rules as outlined above.
(If under 16 years of age, a parent or guardian must agree.)
I HEREBY CONSENT TO TREATMENT AT NATURE MEDICINE INC.
AND FOR MY FILE TO BE REVIEWED BY ANY OF THE MEDICAL STAFF AS IS DEEMED NECESSARY FOR MY BEST HEALTH INTERESTS.
Agree
*
true
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Please note: The more detailed information you provide the more efficient and effective we can be when treating you.
Chief concern additions
Chief Concern #1:
*
When did the concern begin?
*
How often does the concern occur?
*
What is the intensity of the concern? (10 worst)
*
1
2
3
4
5
6
7
8
9
10
How long does the concern last?
*
Is there anything that makes your concern better?
Is there anything that makes your concern worse?
Chief Concern #2:
When did the concern begin?
How often does the concern occur?
What is the intensity of the concern? (10 worst)
1
2
3
4
5
6
7
8
9
10
How long does the concern last?
Is there anything that makes your concern better?
Is there anything that makes your concern worse?
Chief Concern #3:
When did the concern begin?
How often does the concern occur?
What is the intensity of the concern? (10 worst)
1
2
3
4
5
6
7
8
9
10
How long does the concern last?
Is there anything that makes your concern better?
Is there anything that makes your concern worse?
Chief Concern #4:
When did the concern begin?
How often does the concern occur?
What is the intensity of the concern? (10 worst)
1
2
3
4
5
6
7
8
9
10
How long does the concern last?
Is there anything that makes your concern better?
Is there anything that makes your concern worse?
Chief Concern #5:
When did the concern begin?
How often does the concern occur?
What is the intensity of the concern? (10 worst)
1
2
3
4
5
6
7
8
9
10
How long does the concern last?
Is there anything that makes your concern better?
Is there anything that makes your concern worse?
Has an MD ever given you a working diagnosis of this chief complaint?
*
Yes
No
What is that diagnosis?
*
How did the MD medically treat this complaint?
Do you have any medical alerts? i.e. diabetes, allergies to medication
Please tell us:
*
Energy:
How would you rate your energy out of 10 (10=best)?
*
Does your energy changes throughout the day?
*
Yes
No
When is your energy best (morning, afternoon, evening, all day)?
*
When is your energy worst (morning, afternoon, evening, all day)?
*
Are there any factors that increase your energy?
*
Are there any factors that decrease your energy (eg. Stress, weather, sleep)?
*
Sleep:
What time do you go to bed?
*
Do you have trouble falling asleep?
*
Yes
No
Do you have trouble staying asleep?
*
Yes
No
What time do you wake up?
*
Do you have nightmares?
*
Yes
No
Do you have night sweats?
*
Yes
No
Do you snore or have sleep apnea
*
Do you get up to urinate during the night?
*
Yes
No
How many times?
*
Exercise:
Do you exercise?
Yes
No
How many times a week do you exercise?
*
For how long?
*
What type of exercise?
*
Please
check off
those conditions which were a problem for you in the
past
or
present
ly causing you problems.
GENERAL: Do you have any of the following: Present
*
Dizziness
Loss of weight
Weight gain
Fever
Frequent infections
None
GENERAL: Have you had any of the following: Past
*
Dizziness
Loss of weight
Weight gain
Fever
Frequent infections
None
Please elaborate on any of the above conditions you have selected?
Neurological Present
*
headaches/migraines
poor coordination
trembling of any extremity
Convulsions
numbness/tingling
Concussions
Trouble with speech
Difficulty swallowing
Memory problems
Difficulty concentrating
None
Neurological Past
*
headaches/migraines
poor coordination
trembling of any extremity
Convulsions
numbness/tingling
Concussions
Trouble with speech
Difficulty swallowing
Memory problems
Difficulty concentrating
None
When did your headaches start?
*
How often do they occur?
*
How long do they last?
*
Where do you feel the pain?
*
How would you characterize the pain (sharp, dull, etc.)?
*
Are there any specific triggers?
*
Does anything help to relieve the pain?
*
Are there other symptoms associated with your headaches (eg. Light sensitivity, nausea)?
*
Please elaborate on any of the above conditions you selected:
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MIND: Do you have any of the following: Present
*
Can’t work under pressure
Magnify insignificant events
Can’t decide easily
Eat when nervous
Nervousness
Cry easily
Mood swings
Grief
Anxiety
Suicidal tendency
Emotional
Under excessive stress
Fear
Anger
Depression
Low patience
Low self-image
Low morale
Pessimism
Argumentative
Nervous breakdown
Repressed
Worry
Bad temper
none
MIND: Have you had any of the following: Past
*
Can’t work under pressure
Magnify insignificant events
Can’t decide easily
Eat when nervous
Nervousness
Cry easily
Mood swings
Grief
Anxiety
Suicidal tendency
Emotional
Under excessive stress
Fear
Anger
Depression
Low patience
Low self-image
Low morale
Pessimism
Argumentative
Nervous breakdown
Repressed
Worry
Bad temper
none
Please elaborate on any of the above conditions you selected: Are there any recent or past events that have contributed to any of the conditions selected?
MUSCLES AND JOINTS Do you have any of the following: Present
*
stiff neck
foot trouble
hand pain
cramps/spasms
shoulder pain
knee pain
swollen joints
elbow pain
painful tail bone
arthritis
wrist pain
back ache
None
MUSCLES AND JOINTS Have you had any of the following: Past
*
stiff neck
foot trouble
hand pain
cramps/spasms
shoulder pain
knee pain
swollen joints
elbow pain
painful tail bone
arthritis
wrist pain
back ache
None
Pain location(s)?
*
When did it start?
*
How often do you get it?
*
How long does it last?
*
How would you describe the pain?
*
Does the pain radiate to other areas?
*
Does anything make the pain better?
*
Does anything make the pain worse?
*
Are there any other symptoms associated with the pain?
*
Injury history: have you ever had any injuries (sports, car accident, etc)? Have you ever been treated by a chiropractor, physiotherapist, osteopath, acupuncturist, etc?
*
Is there anything else you would like to tell us about the above conditions?
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SKIN: Do you have any of the following: Present
*
Rashes/itching/hive
Eczema
Psoriasis
Pimples
Bruises easily
dandruff
dryness
Changes in hair colour or texture
changes in texture/colour
Changes in skin colour or texture
None
SKIN: Have you had any of the following: Past
*
Rashes/itching/hive
Eczema
Psoriasis
Pimples
Bruises easily
dandruff
dryness
Changes in hair colour or texture
changes in texture/colour
Changes in skin colour or texture
None
Please specify any other skin condition and tell us more about any conditions listed above (eg. Medications or creams used)
EARS Do you have any of the following: Present
*
Ear infections
Poor/failing hearing
Ringing in the ears
Earaches
Itchy or plugged ears
None
EARS Have you had any of the following: Past
*
Ear infections
Poor/failing hearing
Ringing in the ears
Earaches
Itchy or plugged ears
None
EYES Do you have any of the following: Present
*
Do you wear contacts or glasses
Crossed eyes
Eye strain pain
Night/colour blindness
Cataracts
Glaucoma
Macular degeneration
Red watery itchy eyes
Dry eyes
None
EYES Have you had any of the following: Past
*
Do you wear contacts or glasses
Crossed eyes
Eye strain pain
Night/colour blindness
Cataracts
Glaucoma
Macular degeneration
Red watery itchy eyes
Dry eyes
None
NOSE Do you have any of the following: Present
*
Frequent colds
Sinus problems infections
Chronic nasal congestion/mucus
Recurrent nose bleeds
Seasonal/environmental allergies (eg. Dust or ragweed)
Polyps
Broken nose
None
NOSE Have you had any of the following: Past
*
Frequent colds – how many a year?
Sinus problems infections
Chronic nasal congestion/mucus
Recurrent nose bleeds
Seasonal/environmental allergies (eg. Dust or ragweed)
Polyps
Broken nose
None
Frequent colds – how many a year?
*
What type of allergies do you have?
*
When do your allergies occur? e.g, spring, fall
*
Do you take any medication for your allergies?
*
THROAT Do you have any of the following: Present
*
Enlarged glands
Gum problems/canker sores
Copious saliva
Dry mouth
Grinding /clenched teeth
Recurrent sore throat
Phlegm in the throat
Silver coloured dental fillings (amalgams)
None
THROAT Have you had any of the following: Past
*
Enlarged glands
Gum problems/canker sores
Copious saliva
Dry mouth
Grinding /clenched teeth
Recurrent sore throat
Phlegm in the throat
Silver coloured dental fillings (amalgams)
None
What kinds of dental work have you had? ( fillings, crowns, root canals, implants, dentures, etc)
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RESPIRATORY Do you have any of the following: Present
*
chronic cough
pneumonia
spitting up phlegm
spitting up blood
difficult breathing
bronchitis
asthma
None
RESPIRATORY Have you had any of the following: Past
*
chronic cough
pneumonia
spitting up phlegm
spitting up blood
difficult breathing
bronchitis
asthma
None
Do you smoke or have you ever smoked?
*
Yes
No
For how long?
*
At most how much a day?
*
Please elaborate on any of the above conditions you selected.
CARDIOVASCULAR Do you have any of the following: Present
*
rapid beating
high blood pressure
pain over heart
Low Blood Pressure
cold hands/feet
irregular heartbeat
swelling of ankles
hardening of arteries
varicose veins
angina
stroke
Chest pain
None
CARDIOVASCULAR Have you had any of the following: Past
*
rapid beating
high blood pressure
pain over heart
Low Blood Pressure
cold hands/feet
irregular heartbeat
swelling of ankles
hardening of arteries
varicose veins
angina
stroke
Chest pain
None
Please elaborate on any of the above conditions you selected.
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Endocrine Do you have any of the following: Present
*
Hair loss
Abnormal hair growth
Thyroid enlarged
Sleepy after meals
Irritable before meals
Cravings for sweets
Eating relieves fatigue
Faintness if meals delayed
Heart palpitates if misses a meal
None
Endocrine Have you had any of the following: Past
*
Hair loss
Abnormal hair growth
Thyroid enlarged
Sleepy after meals
Irritable before meals
Cravings for sweets
Eating relieves fatigue
Faintness if meals delayed
Heart palpitates if misses a meal
None
Have you been diagnosed with any of the following conditions?
*
Underactive thyroid
Overactive thyroid
Type I Diabetes
Type II Diabetes
None of the above
GASTRO-INTESTINAL Do you have any of the following: Present
*
poor appetite
heartburn
excessive hunger
flatulence
bloody stools
vomiting (blood)/ulcer
liver/gall bladder trouble
jaundice
intestinal worms
abdominal pain
constipation
diarrhea
rectal pain
nausea
hemorrhoids
bloating
None
GASTRO-INTESTINAL Have you had any of the following: Past
*
poor appetite
heartburn
excessive hunger
flatulence
bloody stools
vomiting (blood)/ulcer
liver/gall bladder trouble
jaundice
intestinal worms
abdominal pain
constipation
diarrhea
rectal pain
nausea
hemorrhoids
bloating
None
Bowel Movements:
How many bowel movements do you have a day?
*
Are they complete? Easy to pass?
*
Are they formed/loose/thin/pellets?
*
Have you ever seen mucus or undigested food in the stool?
*
Is there any blood in your stools?
Yes
No
Please elaborate on any of the above conditions you selected
GENITO-URINARY Do you have any of the following: Present
*
troubles urinating
blood in urine
pain on urination
kidney infection
unable to hold urine
frequent urination
kidney stones
urgency
None
GENITO-URINARY Have you had any of the following: Past
*
troubles urinating
blood in urine
pain on urination
kidney infection
unable to hold urine
frequent urination
kidney stones
urgency
None
Please elaborate on any of the above conditions you selected
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Sex:
*
Male
Female
Women m
enstrual history:
How old were you when you began menstruating?
*
Are your cycles regular?
*
Yes
No
How many days does your menstrual period last?
*
Do you ever have excessive flow (more than 4 regular feminine products a day)
*
Yes
No
GENITO-URINARY (WOMEN) Do you have any of the following: Present
*
Clots passed
Cramps
Painful menses
None
GENITO-URINARY (WOMEN) Have you had any of the following: Past
*
Clots passed
Cramps
Painful menses
None
Do you use any type of contraceptive or birth control pill?
*
PMS symptoms: Do you have any of the following: Present
*
Cravings/appetite changes
Breast tenderness
Mood swings
Headaches
Skin breakouts
None
PMS symptoms: Have you had any of the following: Past
*
Cravings/appetite changes
Breast tenderness
Mood swings
Headaches
Skin breakouts
None
Pregnancies:
Have you ever been pregnant?
Yes
No
# of pregnancies:
*
# of children:
*
# of miscarriages/abortions :
*
Complications
*
Fertility difficulties
*
Menopause history:
Have you gone through menopause?
Yes
No
Age of last menstrual period
*
Did you ever take hormone replacement?
*
Women"s general Present
*
hot flashes
Night sweats
Weight changes
Irregular pap smear results (cervical dysplasia)
Fibroids
Endometriosis
sexually transmitted diseases
Hysterectomy
Vaginal yeast infection
vaginal discharge
Lumps in breast
None
Women"s general Past
*
hot flashes
Night sweats
Weight changes
Irregular pap smear results (cervical dysplasia)
Fibroids
Endometriosis
sexually transmitted diseases
Hysterectomy
Vaginal yeast infection
vaginal discharge
Lumps in breast
None
Please elaborate on any of the above conditions you selected
GENITO-URINARY (MEN) Do you have any of the following: Present
*
Enlarged prostate
Other prostate problems
sexually transmitted diseases
impotence
premature ejaculation
None
GENITO-URINARY (MEN) Have you had any of the following: Past
*
Enlarged prostate
Other prostate problems
sexually transmitted diseases
premature ejaculation
impotence
None
What type of sexually transmitted diseases?
*
Impotence - is it intermittent or longstanding
*
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Family History
(eg. Diabetes, heart disease, stroke, asthma, allergies, epilepsy, cancer, high blood pressure, mental disorders, alcoholism)
Maternal side of family
*
Paternal side of family
*
Do your siblings have any health concerns?
*
Yes
No
Do your children have any health concerns?
*
Yes
No
Specify
*
Specify
*
Medication / Supplement
Start Date Medication or Supplement Dose
*
Diagnostic testing
: Please list any recent tests you have had and what was found (eg. X-rays, ultrasounds, MRI’s, CT’s, blood work, biopsies)
Date Test Findings
Have you ever had any of the following illnesses?
*
measles
pneumonia
german measles
influenza
mumps
polio
scarlet fever
meningitis
whooping cough
pleurisy
chicken pox
smallpox
MRSA
TB
H1N1
None
IMMUNIZATIONS Check the illnesses that you have had immunizations for:
*
diphtheria
pertussis
tetanus(DPT, Tdap)
polio(IPV)
measles
mumps
rubella(MMR)
varicella(var, chicken pox)
Pneumococcal (pneumonia)
meningococcal (meningitis)
hepatitis B
twinrix (hepatitis A/hepatitis B)
influenza (flu shot)
haemophilus influenzae type B (Hib)
human papilloma virus (HPV)
yellow fever
smallpox
rabies vaccine
typhoid
rotavirus (Rot-1)
tuberculosis
cholera
None
Whatever was standard during my childhood
Specify which immunizations, if any, that you have had an adverse reaction(s) to:
ALLERGIES (Please check):
*
penicillin or sulfa
other drugs
aspirin/codeine/morphine
foods
mycins or other
antibiotics
None
environmental
Do you have any sensitivities or intolerances to any foods (i.e. foods that make you feel ill?)
SURGERY (Please check):
*
wisdom teeth
appendectomy
None
HOSPITALIZATIONS If hospitalized in the past, what specifically was the reason?
GENERAL DIET (Please check if you presently eat, drink or use.)
*
aluminium pans
microwave food
luncheon meats
margarine
fried foods
fast foods (a lot)
refined sugars
candy
alcohol
coffee/tea
pop
water
None
How many cans of pop a week
*
how much water do you drink per day?
*
how much Coffee/tea do you drink per day?
*
Alcohol : how much per day/week/month? Size of glass?
*
Are there any foods that you avoid (eg. Sugar, caffeine, gluten, dairy)?
*
Do you diet often?
*
Yes
No
How often?
*
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ENVIRONMENTAL
Please check those factors that apply to you
Which water(s) do you drink?
tap
well
bottled
softened
Filtered
Which air(s) are you exposed to?
smog
industrial
cigarette smoke
office building
Which lighting do you use most during your day?
fluorescent
plain lightbulbs
naturally lit
What chemicals are you exposed to?
*
pesticides
paints/lacquers
None
Does your house have any dampness or mold?
*
Have you done any renovations?
*
Yes
No
Do you have any pets?
*
Yes
No
Where did you grow up?
*
Do you live near or have you ever lived near farms or industrial areas?
*
Are you now or have you ever been exposed to any other kinds of dust/chemical/contaminants through a workplace or home
*
What is the approximate age of your house?
*
What is the approximate age of the building you work in?
*
Do you live close to any high voltage power lines?
*
Yes
No
how close?
*
Do you sleep on a water bed or use electric blankets?
*
Yes
No
How long have you been using them?
Generally in regards to temperature, would you describe yourself as a hot person or cold person?
*
How do you feel about the open air?
*
Do you crave sweet or salty foods?
*
Do perspire easily?
*
Are you a thirsty or thirstless person?
*
At what temperature do you prefer your beverages?
*
Do you sip or gulp your beverages?
*
If you are bothered by something, would you let it out or keep it in?
*
How or by whom were you referred to this office (provide E-mail if possible):
Please run the wizard
Thank you for answering all the questions. Complete answers to all of the questions are to your benefit for the most effective naturopathic treatment.
This is a confidential record of your medical history and will be kept in this office. Information contained here will not be released to any person except when you have authorized us to do so.
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