Patient Intake FormBy filling out this comprehensive intake form, you are helping us to provide you with more effective care. We thank you for your time and patience in doing this.

Where did you hear about Living Wellness Centre?

Work TelephoneOccupation

TelephoneName of General Practitioner (MD)

Name of emergency contact

TelephoneRelation to you

May doctor and/or staff contact you at work? Yes No

PATIENT INFORMATION Date

Full Name I go by

Male FemaleBirthday (mm/dd/yy) Age

Care Card Number (PHN)

City Postal Code

Primary Telephone Cellphone

Email

Yes No

Home Address

Office use only MSP Yes No CND Jane W/C GS

Would you like an email reminder for your appointments?

Health History

Are you pregnant?

LIFESTYLE

FOR WOMEN

Type of exerciseHow often do you exercise?

Do you currently smoke?

Overall stress level

Yes No

Yes No Maybe if yes, due date

none low medium high

If yes, by vaginal birth caesarean birthDo you have children? Yes No

Menstrual cycle

Date of your last annual Pap/Breast exam

regular irregular painful cycle

NAME Date

HEALTH ISSUES

Other Concern(s)

Have you ever been treated by any of the following:

Main Concern

Medications

MEDICATIONS

( p r e s c r i p t i o n , over the counter)

Supplements(mult ivi tamins, gingko, etc.)

Please list any medications/supplements you are taking and doses.

Is your condition part of an ICBC or WCB claim? Yes No(If yes, please ask for additional forms.)

Chiropractor NaturopathMassage TherapistAcupuncturist

AdditionalHealth History

SLEEP

DIET

Do you wake well rested in the morning?

Time you go to sleep

Yes No

Time you wake up

Staying asleep?

If yes, please specify:

NAME Date

IMMUNIZATIONS

Check any other vaccines taken:

MEDICATIONS Please check if you use any of the following.

Please list any allergies or sensitivities in the following categories.

Did you receive general childhood vaccinations? Yes No

Hepatitis B OthersFlu shotHepatitis A

Other drugsLaxativesCortisone

Sleeping pills TranquilizersCaffeineAnti-inflammatories

Marijuana Pain relieversAntacidsAlcohol

FAMILY HISTORY Please check if you have a family history of any of the following:

Mental IllnessDrug/alcohol abuseDiabetesStrokeHigh cholesterol Kidney disease

DepressionCancerEpilepsy High blood pressure

Asthma/allergiesArthritis

I don’t know my family history Other

Were you ever on antibiotics for more than 1 month over the last 10 years? Yes No

Have you ever used probiotics (acidophilus) following antibiotic use? Yes No

Do you follow any particular diet regimens or restrictions? Yes No

Do you have problems falling asleep? Yes NoYes No

ALLERGIES

Environmental/chemical

Medications

Foods

Review of systems Please check the appropriate box for any of the following symptoms and add any comments you may feel are important.

Key: P=Past N=Now B=Both

P N B General

Insomnia Fatigue Weight loss Weight gain

Head

Headache Dizziness Head trauma Fainting

Eyes Itching/redness Cataracts Flashes in vision Spots in vision Glaucoma

Mouth and Throat

Bleeding gums Canker sores Colds sores Sore throat Jaw/TMJ problems Hoarseness Goiter

Nose

Hayfever Loss of smell Nosebleeds Sinus problems

Lungs

Asthma Shortness of breath Persistant cough Emphysema Bronchitis

Vascular

Angina Murmurs Chest pain Palpitations Ankle swelling Cold feet/hands Leg cramps Varicose veins Low blood pressure High blood pressure

P N B Gastro-Intestinal

Bloating/gas Heartburn Ulcers Liver disease Gallstones Vomiting/nausea Abdominal pain Diarrhea Constipation Blood in stool Hemorrhoids Hernias

______ # of bowel movements per day Genitourinary

Pain urinating Blood in urine Incontinence Bed-wetting Frequent urination Frequent infections Kidney stones

Neurological

Seizures/epilepsy Strokes Tingling sensation Numbness Muscle weakness Poor coordination Paralysis Speech problems Loss of memory

Muscle & Bone

Joint pain Swollen joints Muscle ache Foot trouble Bone pain Fractures Dislocations

P N B Skin

Rash Itching Hives Change in moles Acne Psoriasis Eczema

Endocrine

Diabetes Hypoglycemia Hormone therapy Thyroid problems Heat/cold

intolerance Excessive thirst Excessive hunger Excessive sweating Night sweats

Emotional

Depression Mood swings Anxiety/nervousness Tension Phobias

Conditions

AIDS/HIV Eating disorders Heart disease Rheumatic fever Cancer/tumor Polio Parkinson’s Multiple sclerosis

Gout

Anemia Osteoporosis Osteoarthritis High cholesterol Fibromyalgia Chronic fatigue Hepatitis

Migraines

TIAs

DIET DIARY Name: ________________________ Start Date:___________

Monday Day ___

Tuesday Day ___

Wednesday Day ___

Thursday Day ___

Friday Day ___

Saturday Day ___

Sunday Day ___

Breakfast

Lunch

Dinner

Snacks

Fluids

BM

Energy

Comments

** BM = Bowel Movements. Please feel free to write on the back of the sheet if more space is required.

Tell Me About Yourself!

I _____________ cooking!

How many times a week do you currently eat the following:

Chicken: Pork: Beef: Turkey: Fish: Other:

What are your top 5 favourite meals/cuisines?

1._____________________________

2._____________________________

3._____________________________

4. _____________________________

5. _____________________________

Do you have any health goals? (e.g. weight loss, increased energy, etc.)

______________________________________________________________________

The Specifics Do you have food allergies?

Yes: No:

If yes, what foods?

______________________________________________________________________

What is the severity of the reaction?

______________________________________________________________________

Do you have dietary restrictions?

Celiac: Gluten Free: Vegan: Vegetarian:

Other:

Do you have food sensitivities or unpleasant reactions to certain foods? (beans, garlic, meat, etc.)

______________________________________________________________________

If yes, to which foods?

______________________________________________________________________

Are there any foods you will not eat?

_____________________________________________________________________

Where do you typically buy your groceries?

______________________________________________________________________

How do you feel about leftovers for lunches?

______________________________________________________________________

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Registered Holistic Nutrition Declaration

& Consent to Treatment

Please read, complete and sign this Client and Consent Agreement. It will explain in detail the services that I, Samantha deSousa, a Registered Holistic Nutritionist, can provide to you. This Agreement will also provide details as to how your personal information will be used for the sole purpose of the services that I provide. I understand the importance of protecting your personal information and will collect only the information needed for a nutritional a/o physical based assessment. CLIENT AGREEMENT I agree to, Samantha deSousa RHN, collecting personal information about me as set out above. I understand and agree that, Samantha deSousa RHN, will keep all documents related to me, included but not limited to any assessment, food diaries, forms, worksheets or any notes that relate to me, as a record of our work together. I understand and agree that, Samantha deSousa RHN, may use any information gathered to document the topics that we discuss about my progress or plans that may be helpful to my health and wellness. Any and all information will be stored in a secure location and any medical records, personal information and health history provided to Samantha deSousa RHN will be kept in strict confidence unless I provide consent to have them released. I may look at and request a copy of my records at any time. I understand and agree that each individual is unique and it will not be possible to determine in advance how my body/system may react to certain foods, drinks or supplements that may be suggested to me. I understand and agree that it may be necessary to adjust my plan from time to time or until such time that my body can properly accept nutritional changes. I understand and agree that it is my responsibility and decision to use or disregard any nutritional and/or lifestyle guidelines.

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I agree to hold Samantha deSousa, RHN harmless for any and all claims or damages in connection with our work together under the terms of this Agreement. I understand and agree that this Agreement is also a release of her liability. I understand and agree that any advice under this program is not a substitute for medical treatment or a varied diet and that all components have been explained to me but I am free to ask any questions that I may have. I understand and agree that after all advice and assistance has been provided to me by Samantha deSousa RHN, that I may withdraw at any time after all fees have been paid in full. Consent Agreement I hereby confirm and agree to the following:

1. I fully understand that Samantha deSousa, RHN, is not a medical doctor and I am not here for medical testing or treatment procedures. If I have any health matters, conditions or disease I have been advised to seek competent medical advice from a licensed practitioner of medicine. I understand and agree that any service provided by an RHN is not designed to cure or prevent any disease, pain, injuries, mental or physical conditions of any kind.

2. I acknowledge that the services performed by Samantha deSousa, RHN is at all times restricted to consultation with respect to nutrition for building wellness and does not involve diagnosing, treatment or prescribing of remedies for the treatment of any disease or for anything that requires a medical license.

3. This agreement is being signed voluntarily and not under the duress of any kind.

4. I have attended this visit, and any subsequent visit(s), solely on my own behalf and not as an agent for any federal, provincial or municipal agency on a mission of any entrapment or investigation.

5. I have read this Consent Agreement, fully understand its terms, understand that I have given up certain rights by signing it and am signing it freely and voluntarily, without any duress or inducement.

6. I understand that completing this form will form part of a legal and binding agreement.

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7. I am aware that 48 hours notice is required for appointment cancellations or a cancellation fee may be applied.

8. I understand that Samantha deSousa, RHN reserves the right to decide which cases are outside of her scope of practice, in which case a referral will be suggested.

I have read this agreement and fully understand its terms. Signature Date Name Registered Holistic Nutritionist Signature