NSNC Intake Form - Northshore Naturopathic Clinic · Northshore Naturopathic Clinic 156 W 3rd St...

Northshore Naturopathic Clinic 156 W 3rd St

North Vancouver, BC V7M 1E8 T: 604 986 7774 F: 604 986 3926

[email protected] northshorenaturopathicclinic.ca

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Comprehensive Adult Naturopathic Intake Form

Successful comprehensive health care is only possible when the physician has a complete understanding of the patient’s physical, mental and emotional condition and history. Please answer each question as thoroughly as

possible. Your time, thoughtfulness and honesty is appreciated and will greatly aid us in evaluating your health needs. Please mark anything you do not understand with a question mark.

All information is completely confidential.

PERSONAL INFORMATION

Name: Age: Sex: Male Female

Home Address: DOB (MM/DD/YYYY):

City/Province: Marital Status:

Postal Code: Children (Sex/Age):

Home Phone: Work Phone:

Email: Cell Phone: (to receive appointment reminders)

Occupation: BC Care Card:

Names of other Healthcare Providers:

Medical Doctor: Massage Therapist:

Chiropractor: Specialist:

Person to contact in case of Emergency:

Relationship to you: Cell Phone:

Home Phone: Work Phone:

How did you hear about us? Newspaper ad Friend Yellow pages Website Other

PAST MEDICAL CARE

Have you received Naturopathic Care previously? Yes No When:

Name of Naturopathic Physician:

For what reason?

Have you received Chiropractic Care previously? Yes No When:

Name of Chiropractor:

For what reason?

Date of last visit to Medical Doctor (MD/GP):

Date of last blood test:

Do you get regular screening tests done by another doctor? (pap, blood, prostate, etc…) Yes No

Date: _____________

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It’s time to see a Naturopathic Physician Acupuncture | Homeopathy | IV Therapy | Nutritional Counseling | Allergy and Lab Testing | Detoxification




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PRIMARY HEALTH CONCERNS (please list in order of importance to you)

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2

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Have you been given any diagnoses?

Please list all former treatments that you have used for your above concerns, both conventional and alternative, and the degree of effectiveness of each treatment:

Treatment Practitioner Date Results

CURRENT MEDICAL CONTEXT

Do you have any contagious diseases at this present time? oYes oNo

Do you have any known life threatening Allergies? oYes oNo

What symptoms do you experience with an allergy attack?

Other allergies, intolerances and sensitivities (non-life-threatening):

Symptoms experienced:

Do you have a pacemaker? oYes oNo

Do you wear glasses or corrective lenses? oYes oNo

Women only: Are you currently pregnant? oYes oNo Number of Weeks:

Have you traveled outside of Canada in the past year? oYes oNo

Do you frequently use any of the following?

Aspirin o Laxatives o Cortisone o

Diet Pills o Antacids o Antibiotics o

Pain relievers o Hormones o Sedatives / Sleeping pills o

Tobacco o Form: Amount per day:

Recreational drugs o Form: Frequency:

Have you ever been treated for an addiction? oYes oNo

of 11It’s time to see a Naturopathic Physician

Acupuncture | Homeopathy | IV Therapy | Nutritional Counseling | Allergy and Lab Testing | Detoxification




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MEDICATIONS AND SUPPLEMENTS

Please list all of your present medications including drugs, prescription medications, supplements, homeopathics and herbs along with dosages.

Medication Dosage Reason for Taking Start Date

Approximately how many times have you been treated with antibiotics?

MEDICAL HISTORY

Please indicate what immunizations you have received:

DPT (diphtheria, pertusis, tetanus) o Haemophilus influenza o Polio o MMR (measles, mumps, rubella) o Hepatitis A o Hepatitis B o

Smallpox o Tetanus Booster o Flu o Meningitis o Chickenpox o Gardasil / HPV o

Other o

What childhood illnesses have you had?

Rubella (German Measles – 3 days) o Measles (2 weeks) o Mumps o Chicken Pox o Whooping Cough o Polio o

Rheumatic Fever o Scarlet Fever o Roseola o Asthma o Diphteria o Ear Infection(s) o

Tonsilitis o Mononucleosis o Strep Throat o Other o

Please check if you have received any of these allergy tests:

Intradermal o Scratch o Applied kinesiology o Food intolerance testing o Blood IgE inhalant/food o Blood IgG food o

Other: o

Please indicate any serious conditions, illnesses or injuries and any hospitalizations or surgeries:

Event Approximate Dates

Please indicate any adverse reactions, if any:

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Are there any traumatic events (surgeries, drug reactions, life trauma) that you feel may have caused or contributed to your health problems?

Event Approximate Dates

Do you suffer or have you ever suffered from any of the below?

Now Past Never Now Past Never

Anemia o o o High Blood Pressure o o o Allergies o o o Hyperthyroid o o o Alcohol Abuse o o o Hypoglycemia o o o Arthritis o o o Kidney Disease o o o Asthma o o o Liver dz/Jaundice o o o Bleeding o o o Overweight o o o Cancer o o o Pneumonia o o o Candida o o o Rheumatic Fever o o o Colitis o o o Rheumatism o o o Diabetes o o o Sexually Transmitted Infections o o o Drug Use o o o Syphilis o o o Eczema o o o Tuberculosis o o o Emphysema o o o Ulcers o o o Headaches o o o Other o o o Heart Murmur o o o

FAMILY HISTORY:

Please indicate if any close relative has had any of the following:

Condition Relation Condition Relation Condition Relation

Alcoholism Depression Mental Disease

Allergies Diabetes Muscular Dystrophy

Anemia Drug Abuse Multiple Sclerosis

Arteriosclerosis Eczema Seizure / Epilepsy

Arthritis Glaucoma Schizophrenia

Asthma Gout Sexually Transmitted Infections

Bleeding Hay Fever Sickle Cell Anemia

Cancer Heart Disease Stroke

Cataracts High Blood Pressure Stomach ulcers

Celiac Hyperactivity / ADD Thyroid (hyper/hypo)

Colitis Kidney Disease Tuberculosis

Dementia Learning Disability Other






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LIFESTYLE

Exercise:

Do you exercise regularly? oYes oNo How often? For how long?

Types of activities/sports?

Stress and Relaxation: How stressful is your work? Not at all Somewhat Moderately Very / Always

Do you enjoy your work? Not at all Somewhat Moderately Very / Always

How stressful is your home life? Not at all Somewhat Moderately Very / Always

On a scale of 1 to 10 (where 1 is the lowest and 10 is the highest), where would you rate your overall stress levels?

1 2 3 4 5 6 7 8 9 10

How well do you handle these stresses? Poorly Fairly Well Very well

On a scale of 1 to 10 (where 1 is the lowest and 10 is the highest), where would you rate your overall energy levels?

1 2 3 4 5 6 7 8 9 10

Do you have supportive relationships? oYes oNo

Do you have a religious or spiritual practice? oYes oNo

Do you make time for rest, relaxation or meditation during the day or before bed? oYes oNo

What do you do for relaxation?

What behaviours or lifestyle habits do you currently engage in regularly that you believe support your health?

What behaviours or lifestyle habits do you currently engage in regularly that you believe do not support your health?

Sleep:

Do you have trouble falling asleep? oYes oNo Do you have trouble staying asleep? oYes oNo

Do you wake up feeling rested? oYes oNo How many hours of sleep/night?

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Diet:

Are you satisfied with your present weight? oYes oNo

Have you ever had a weight problem? oYes oNo

Do you have any dietary restrictions? oYes oNo (religious, vegetarian, etc.) (specify restrictions)

Do you regularly consume any of the following?

Frequency (ex: 4 times/week) Quantity

Coffee

Caffeinated Teas

Alcohol

Processed Foods

Refined Foods

Other:

Please list any other food you consume you suspect may be harmful to your health:

Please list any foods that you crave, regardless of their nutritional value (ex: chocolate, bread, salty snacks, rich/fatty foods):

Approximate amount of water consumed during the day:

Describe a typical day’s diet (please include beverages):

Breakfast

Snack

Lunch

Snack

Dinner

Snack






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REVIEW OF SYSTEMS

Please check the appropriate box for any of the following symptoms which you now have, or have had previously. If symptom does not apply, please leave blank. We need as many facts as possible about

your health to assist us in your care.

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General

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Mouth / Throat

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Respiratory o o o Easily fatigued o o o Grinding of teeth o o o Coughing up blood o o o Nervousness / anxiety o o o Speech difficulties o o o Chest pain when breathing o o o Failing memory o o o Bleeding gums o o o Wheezing o o o Easily stressed o o o Loss of teeth o o o Difficulty breathing at night o o o Mood swings o o o Cold sores, blisters o o o Chest congestion o o o Difficulty concentrating o o o Silver/mercury fillings (teeth) o o o Excessive sputum (mucous) o o o Irritability / restlessness o o o Persistent hoarseness o o o Shortness of breath o o o Mental confusion o o o Difficulty swallowing o o o Daily cough o o o Night sweats o o o Loss of voice o o o Other:

o o o Mental slowness o o o Chronic sore throat or pain

o o o Depression / suicidal thoughts o o o Copious saliva Cardiovascular o o o Flushing / get hot easily o o o Sore tongue / lips o o o Chest pain on exertion o o o Insomnia o o o Other: o o o Ankle or abdominal swelling o o o Excessive thirst o o o Heart palpitations

o o o Other: Gastrointestinal o o o Varicose veins o o o Constipation o o o Numbness / tingling in arm/leg

Skin o o o Diarrhea o o o Heart murmur o o o Dry, rough, scaly, itchy skin o o o Alternating const/diarrhea o o o Slow heart beat o o o Rashes, hives o o o Strain at stool o o o Rapid heart beat o o o Warts o o o Hemorrhoids o o o Poor circulation o o o Recent / changes in moles o o o Black stool o o o Low blood pressure o o o Light/dark patches of skin o o o Blood in stool o o o High blood pressure o o o Pimples / acne o o o High/low # of bowel movement o o o Other: o o o Loss of hair o o o Vomiting blood

o o o Nails: colour changes, ridges, pits or white spots

o o o Frequent or severe nausea

Endocrine o o o Other: o o o Heartburn / indigestion o o o Unexplained weight loss / gain

o o o Trouble swallowing o o o Cold / heat intolerance

Head o o o Distress from fat/greasy food o o o Cold hands and feet o o o Dizziness o o o Bad breath / taste in mouth o o o Fatigue o o o Severe headaches o o o Shaky: better after sugar o o o Seasonal depression o o o Seizures, convulsions o o o Cravings: sweets & alcohol o o o Increased thirst o o o Double vision o o o Cravings: salt o o o Increased hunger

o o o Loss of balance / fainting spells o o o Irritable if miss meal o o o Other: o o o Other: o o o Appetite increase / decrease

o o o Diet but fail to lose weight Muscles / Joints

Nose / Ears / Eyes o o o Eat but fail to gain weight o o o Joint paint, stiffness, swelling o o o Nose bleeds o o o Excessive belching o o o Neck pain / stiffness o o o Sinus congestion o o o Excessive lower bowel gas o o o Pain between shoulders o o o Loss of smell o o o Stomach cramps, colic o o o Low back pain o o o Excessive ear wax o o o Abdominal bloat, distension o o o Muscle weakness o o o Hearing problems o o o Anorexia / bulimia o o o Muscle cramps o o o Sensitivity to noise o o o Stomach / abdominal pain o o o Arthritis o o o Pain in ears o o o Yellow / jaundice o o o Tremors (shaking / trembling) o o o Ringing in ears o o o Frequent vomiting o o o Numbness o o o Light sensitivity o o o Other: o o o Paralysis o o o Blurred / Double vision o o o Sciatica o o o Dry eyes, nose, mouth Bowel movements: How often? o o o Specific area pain: o o o Other: Is this a change? o Yes o No o o o Other:

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REVIEW OF SYSTEMS (CONT’D)

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Lymphatic / Immune

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Female Reproductive

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Male Reproductive o o o Painful / swollen lymph nodes o o o Lumps in breast(s) o o o Testicular pain / swelling o o o Difficulty stopping bleeding o o o Nipple discharge o o o Testicular mass(es) o o o Unexplained fever o o o Breast pain / tenderness o o o Hernias o o o Bruising easily o o o Absent menstruation o o o Premature ejaculation o o o Wounds heal slowly o o o Excessive menstrual flow o o o Erectile dysfunction o o o Fluid retention o o o Irregular menstruation o o o Discharge / sores o o o Other: o o o Painful menstruation o o o Painful erection

o o o Spotting between periods o o o Low libido

Genito-urinary o o o PMS o o o Other: o o o Pain on urination o o o Menopausal symptoms o o o Blood in urine o o o Vaginal discharge o o o Bed-wetting o o o Vaginal itching / burning o o o Frequent urination o o o Genital eruptions / sores o o o Kidney stones o o o Pelvic pain o o o Frequent infections o o o Pain during intercourse o o o Inability to hold / control o o o Low libido o o o Wake up to urinate o o o Difficulty conceiving o o o Odd smell / colour of urine o o o Other: o o o Difficulty in starting urination o o o Other:

REPRODUCTIVE HEALTH:

Are you sexually active at the moment? oYes oNo Type of birth control used:

Men’s Health:

Do you perform regular testicular self-exams? oYes oNo

Date of last prostate exam: Was it normal? oYes oNo

Women’s Health:

Do you perform regular breast self-exams? oYes oNo Age of first menstruation

Date of last pap smear: Was it normal? oYes oNo

Length of cycle Duration of menses Date of last menses (Days) (Days)

# of pregnancies: # of births: # of miscarriages: # of abortions:

GOALS AND EXPECTATIONS:

What long term goals and expectations do you have from working with our clinic?

Thank you for your time and effort! We look forward to providing you with the best possible care. J






Declaration and Informed Consent to Naturopathic Care

I would like to take this opportunity to welcome you to our clinic. As a Naturopathic Physician we will conduct a thorough case history, a physical exam, and may utilize specific blood and/or urinary laboratory reports as a part of the treatment work-up. We use supportive therapies such as nutrition counseling, botanical medicine, acupuncture, Chinese medicine, supplementation, bodywork, injections, IV therapy, homeopathy and lifestyle counseling to assist the body’s innate healing capacity and to improve overall health and wellbeing.

Statement of Acknowledgement

Printed Name:

As a patient of the Northshore Naturopathic 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 recognize that even the gentlest therapies potentially have their complications. The information provided is complete, accurate and inclusive of all health concerns including the risk of pregnancy and all medications, including over the counter drugs and supplements. Slight health risks of some naturopathic treatments include, but are not limited to: temporary aggravation of pre-existing symptoms, allergic reaction to supplements or herbs, pain, fainting, bruising or injury from venipuncture or acupuncture, muscle strains and spasms, and disc injuries from spinal manipulations.

I also recognize the following:

With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me by the physician at Northshore Naturopathic Clinic or any of its personnel regarding cure or improvement of my condition. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time.

I have had full opportunity, before signing this Informed Consent document, to ask any questions of my Naturopathic Physician about the various diagnostic alternatives, treatments and procedures that he or she uses.

I understand that the Naturopathic Physician reserves the right to determine which cases fall outside of his or her scope of practice, in which event an appropriate referral or recommendation may be made.

I 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 when law requires it. I understand that I may look at my medical record at anytime and can request a copy or have a report drawn up by paying the appropriate fee. I understand that information from my medical record may be analyzed for research purposes and that my identity will be protected and kept confidential.

I understand that my Naturopathic Physician will answer any questions that I have to the best of his/her ability. I do not expect the naturopathic doctor to be able to anticipate and explain all the risks, side effects and complications. I will rely on the Naturopathic Physician to exercise their judgment during the course of the procedures which they feel are in my best interest.

I promise that I will contact my Naturopathic Physician or one of his staff, as soon as possible, if I believe that I am experiencing any unexpected or unusual symptom or unfavorable adverse event or condition as a result of or connected with any diagnosis or treatment.

The clinic requires 24 hours notice of cancellation of a schedule appointment. Failure to provide 24 hours cancellation notice will result in half of the original fee. Less than 24 hour notice for treatments purchased in a package will result in a loss of that session.






I understand the importance of arriving on time for appointments. No extensions or alteration of fees will be granted, unless deemed appropriate or necessary by the naturopathic doctor. I have read, understood, and acknowledged the above statements.

Notice to pregnant women; all female patients must alert the doctor if they know or suspect that they are pregnant as some of the therapies could present a risk to the pregnancy

Signature: _____________________________________________

Print Name: ____________________________________________

Date: _________________________________________________

Northshore Naturopathic Clinic156 W 3rd St, North Vancouver, BC V7M 1E8

Tel: 604 986 7774 Fax: 604 986 3926www.eatingalive.com

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Fee Schedule 2014

The BC Medical Services Plan (MSP) does not subsidize services below at present. Although, several private insurance companies (extended health insurance coverage) now provide at least partial coverage of the procedures listed below. Please contact your individual provider to confirm what is covered.

- Please ask for information on other tests or IV services that may not be listed here. - Lab results cannot be given over the phone. A follow up visit is required to review all results. - Payment for all Health Services and prescribed supplements are due in full when the service is rendered,

by cash, debit, Visa or Mastercard. - Any prescribed supplements are not included in the above fees. - Cancellation of office visits without 24-hour notice will be subject to a 50% of consultation or IV fee

representing time - set aside for the visit.

I have read, fully understand and agree to honor the fee schedule listed above.

Date: ____________________________________________

Signature_________________________________________

Initial Visits Cost

Initial visit including diet explanation & in-house testing

$230.00 - 2 hrs

Return Visits Cost Regular Return Visit $78.00 - 30 mins Extended Return Visit $90.00 - 40 mins Short Return Visit $59.00 - 20 mins

Treatment Visits Cost

Acupuncture Visit $90 or package of 5 for $400.00 - 1 hr

Neural therapy $60.00 - $90.00 Prolotherapy $90.00

Additional Services Cost

Natural Immune Booster $25.00 Natural Allergy Booster $20.00 Traumeel Injection $33.75 Cardiovascular & Adrenal Test

$38.00

Blood Picture $ 20.00

IV and IM Treatments

IV Therapy Cost

NaEDTA Chelation $ 202.25 3 hrs CaEDTA Chelation $ 122.45 1 hr Glutathione Push $66.00 20 mins Vit C Meyers $88.30 40 mins Vit C 10g $108.35 40 mins Vit C 15g $114.55 40 mins Vit C 20g $ 120.20 40 mins Vit C 25g $125.80 40 mins Vit C 30g $131.40 40 mins Vit C 40g $142.65 40 mins Vit C 45g $148.25 40 mins Vit C 50g $153.85 40 mins Vit C 55g $159.50 40 mins Glycerrhiza $134.85 40 mins Vit B12/ Folate $16.85

Lab Visits and Tests

Lab Visits Cost

Blood Draw $20.00 Toxic Metals Test (various)

$137.50 - $252.95

Food Allergy Blood Test (ELISA)

$224.00 / 96 foods $336.00 / 184 foods

NSNC Intake Form - Northshore Naturopathic Clinic · Northshore Naturopathic Clinic 156 W 3rd St...

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Transcript of NSNC Intake Form - Northshore Naturopathic Clinic · Northshore Naturopathic Clinic 156 W 3rd St...