Naturopathic adult-child patient pkg

CONTACT INFORMATION
Last Name: ______________________First Name: _________________Initial:______ Date of Birth: _______________________________________ Age: _______________ Sex: Male Female Ethnicity: ____________________________________ Occupation: ____________________________________________________________ Marital Status: ________________________No. of Dependents: ________________ Address: ______________________________________________ Apt. #____________ City: ______________________________Province:____________________________ Postal Code: ______________ Email: ______________________________________ Preferred form of contact for reminder/follow-up calls: Home Work Email Other – Please specify________________________ Emergency Contact Name: _____________________________________________ Name of Medical Doctor: _______________________________________________ Address: _________________________________________________________________ City: ______________________________ Telephone: __________________________ How did you hear of pureBalance Wel ness Centre? _______________________ Would you like to receive our “Touch of Balance” monthly e-Newsletter?  No  Yes (please ensure your email is listed above) Were you referred to me, if so by whom so we can thank them? ____________ __________________________________________________________________________ pureBalance Wel ness Centre • 106 Lakeshore Road East • Unit C • Mississauga • Ontario • L5G 1E3 ACKNOWLEDGEMENT AND INFORMED CONSENT
I would like to take this opportunity to welcome you. This health clinic utilizes the principles of naturopathic medicine and other supportive therapies to assist the body’s own ability to heal and to improve the quality of life and health through natural means. I will conduct a detailed case history, conduct a physical exam and may utilize specific blood and/or urinary laboratory reports as part of the treatment work-up. Some treatments or procedures may include: nutrition, herbs, homeopathy, acupuncture, naturopathic manipulation, All female patients must inform the doctor if they know or suspect that they are pregnant; as some of the therapies used could present a risk to the pregnancy. As a patient of this clinic I have read the information and understand that the form of medical care is based on naturopathic and other supportive principles and practices. I also understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others unless so directed by myself or unless it is required by law. I also recognize the potential risks that include, but are not limited to: aggravation of pre-existing symptoms, allergic reactions to supplements or herbs, pain, fainting or bruising from venipuncture or acupuncture, muscle strains and sprains from spinal manipulations, inconvenience of lifestyle In order to comply with the regulations as set out in the Personal Information Protection and Electronic Documents Act (PIPEDA), the following policy has been developed. All health care professionals are all trained in the appropriate uses and protection of your information. I also confirm that I have the ability to accept or reject this care of my own free will and choice and that I am not an agent of any private, local, county, provincial, or federal agency attempting to gather information without so stating. I accept full responsibility for any fees incurred during care and Ful Name (please print):____________________________________________ Signature: __________________________ Date: _______________________ Witness _____________________________ Date: _______________________ Print parent/guardian’s name ______________________________________ Signature of parent/guardian _______________________________________ pureBalance Wel ness Centre • 106 Lakeshore Road East • Unit C • Mississauga • Ontario • L5G 1E3 ADULT / CHILD INTAKE FORM

Please fill out this form to the best of your ability. It will help to assess your present health and will assist in
facilitating the healing process.

Name: ___________________________________________________________________________________________
Gender:  Male  Female
Age: ____ Height: ________ Weight: ________
Max Weight: ________ When? ________________________

Are you currently under the care of another healthcare provider?  No  Yes, specify ___________________
______________________________________________________________________________________________________
What are your chief concerns?
1.____________________________________________________________________________________________________ 2.____________________________________________________________________________________________________ 3.____________________________________________________________________________________________________
Please list all medications (prescription, over-the-counter) you are currently taking:
Medication
Dose/Quantity per day
Why are you taking this product?

Please list all natural products (vitamins, minerals, herbal medications, Asian medicine, homeopathic) you
are currently taking:
Natural Product
Dose/Quantity per day
Why are you taking this product?

Have you ever experienced adverse effects or an allergic reaction to any of the medications/natural
products?  No  Yes, specify: _______________________________________________________________________

Have you ever used any of the following in the last 5 years?
 Anesthesia
pureBalance Wel ness Centre • 106 Lakeshore Road East • Unit C • Mississauga • Ontario • L5G 1E3
Please check off any condition(s) you have experienced or are currently experiencing:
Please list any al ergies or sensitivities you currently have or have previously experienced: 1.____________________________________________________________________________________________________ 2.____________________________________________________________________________________________________ 3.____________________________________________________________________________________________________ What type of vaccinations have you received (Gardasil, Travel related, etc.)? ______________________________________________________________________________________________________ ______________________________________________________________________________________________________
Please list all hospitalizations, surgeries and/or accidents you have experienced:
Description
Outcome/complications?

How much water do you drink per day? _______________________________________________________________
How many times per week do you consume wheat? ____________________________________________________
How many times per week do you consume dairy products? ____________________________________________
How many times per week do you consume red meat? _________________________________________________
What foods do you crave? ____________________________________________________________________________
Do you have any dietary restrictions?  No  Yes, specify: ______________________________________________
FAMILY HEALTH HISTORY

Have any of your family members had any significant illness or health concerns?
Mother: ______________________________________________________________________________________________ Father: _______________________________________________________________________________________________ Sister: ________________________________________________________________________________________________ Brother: ______________________________________________________________________________________________ Maternal grandparents: _______________________________________________________________________________ Paternal grandparents: _______________________________________________________________________________ pureBalance Wel ness Centre • 106 Lakeshore Road East • Unit C • Mississauga • Ontario • L5G 1E3
LIFESTYLE
Have you ever been a smoker?  No  Yes – How many times per day? ___________ How Long?__________
Are you exposed to second hand smoke?  No  Yes – How often? _____________________________________
Do you consume alcohol?  No  Yes – What type(s) and how often? ___________________________________
Do you exercise?  No  Yes – What kind of exercise and how often? ___________________________________
Do you have any surgical implants (Cosmetic, medical, etc.)? ___________________________________________
Have you had any dental work done?  No  Yes – Specify: ____________________________________________
List your hobbies or interests: ___________________________________________________________________________
What level of personal stress are you experiencing at the present moment?
(1=low 10=high)
What are your top three stressors in your life? ___________________________________________________________
______________________________________________________________________________________________________
Has there been an event in your life that you have never recovered from?  No  Yes – Specify: _________
______________________________________________________________________________________________________

ENVIRONMENTAL TOXINS
Do you have any mercury dental fil ings?
Have you ever lived near a pol uted area/power line? Are you particularly sensitive to scents (Perfumes, gasoline, etc)? Have you ever experienced health problems after doing renovations or having your lawn sprayed with pesticides? Have you ever been exposed to mold, solvents, lead paint, heavy metals, fumes or other toxic substances at work, home (renovations, hobbies, etc.) or while traveling?

REVIEW OF SYSTEMS
Please check off any condition(s) you have experienced or are currently experiencing:

SKIN, HAIR, NAILS
 Acne (pimples)

HEAD, EAR, EYES, NOSE, THROAT, MOUTH, NECK
 Blind spot

RESPIRATORY
 Asthma
pureBalance Wel ness Centre • 106 Lakeshore Road East • Unit C • Mississauga • Ontario • L5G 1E3
CARDIOVASCULAR
 Angina

GASTRO-INTESTINAL
 Belching/Passing Gas

URINARY
 Blood in urine

MEN’S HEALTH

WOMEN’S HEALTH
Are you or have you been

MUSCULOSKELETAL
 Arthritis

PERIPHERAL VASCULAR
 Cold hands/feet

BLOOD/LYMPHATIC
 Anemia

NEUROLOGICAL
 Fainting

EMOTIONAL
 Alcohol/Drug abuse

HORMONAL
 Change in weight
pureBalance Wel ness Centre • 106 Lakeshore Road East • Unit C • Mississauga • Ontario • L5G 1E3 How many hours of sleep do you get each night? ___________________________ Do you wake feeling refreshed and well rested? ___________________________ 1. Why did you choose to come to this clinic? ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 2. What do you know about our approach? ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 3. What three expectations do you have from this visit to our clinic? ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 4. What is your present level of commitment to address any underlying causes of your signs and symptoms that relate to your lifestyle? (Rate from 0 to 10, 10 being 100% committed)
Wheel of Balance
Wel ness is a balance of many factors. Using the circle, shade your level of satisfaction in each area as it relates to you. For example, if you are extremely happy in your career, shade the entire pie shape for Do the same for each area, starting from the center point radiating outwards.
Family &
This is your medical history; this document is confidential information and wil not be released to any persons without your consent. Thank-you for completing the questionnaire. pureBalance Wel ness Centre • 106 Lakeshore Road East • Unit C • Mississauga • Ontario • L5G 1E3

Source: http://mypurebalance.ca/wp-content/uploads/2011/04/PBW-Naturopathic-Adult-Child-Patient-Pkg.pdf