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:_______________________________