Naturopathic Adult Intake Form - Niagara Naturopaths, Physiotherapy, and Massage

289-271-2788
4161 Portage Rd, Niagara Falls ON L2E6A2

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Niagara Natural Fertility

Naturopathic Adult Intake Form

* Indicates required field

Date *

Name *

First

Last

Birth Date *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone Number *

Occupation *

Insurance Provider *

Emergency Contact Name *

Emergency Contact Phone Number *

How did you hear about our clinic? *

Google ad Yellowpages online Niagara Healers website Facebook or Twitter Other online source Word of mouth Newspaper or Magazine Clinic sign The Peanut Mill Naturally Healthy Other

Your Other Healthcare Providers (please provide their name, specialty, and phone number) *

What are your chief concerns? (please list in order of importance to you) *

MEDICAL HISTORY (please list each of your medical conditions and the year of diagnosis for each condition) *

ALLERGIES (please list any allergies you have - medications, foods, pets, environmental, etc) *

VACCINATIONS/IMMUNIZATIONS RECORD (please check all that you have received): *

Flu vaccine Tetanus booster Polio Varicella (Chicken pox) Human Papilloma Virus(HPV)/Gardasil DPT (Diptheria, Pertussis, Tetanus) Pneumococcal conjugate (meningitis, pneumonia) Hepatitis B Hepatitis A Haemophilus influenza B MMR (mumps, measles, rubella) Meningococcal C conjugate (meningitis) BCG (Tuberculosis) Other

Did any of your vaccines cause adverse reactions? If yes, please describe: *

Do you carry an EpiPen? *

Yes No

FAMILY HISTORY (please list each health condition and which family member(s) it relates to) *

When was your last physical exam? *

List all of your current prescription medications *

How many times have you been treated with antibiotics in the past 5 years? *

List all over-the-counter medications that you take (eg., Aspirin, Tylenol, Tums), including dose and frequency *

List all vitamins, minerals, herbs, or homeopathic supplements you are taking, including the dosage: *

PLEASE CHECK OFF ANY OF THE FOLLOWING SYMPTOMS IF THEY APPLY TO YOU:

General *

Change of appetite Fatigue Fever Sweat easily Cravings Weight gain Peculiar tastes or smells Poor sleep Chills Night sweats Sudden decrease in energy Strong thirst Weight loss Bleed or bruise easily

Head, Eyes, Ears, Nose, and Throat *

Headaches Concussions Glasses Eye pain Blurry vision Earaches Ringing in ears Nose bleeds Jaw clicks Facial pain Sores on lips, tongue, or mouth Head or neck problems Eye strain Night blindness Colour blindness Cataracts Poor hearing Sinus problems Teeth problems Gums bleed easily Recurrent sore throats

Gastrointestinal *

Indigestion Bad breath Abdominal cramps/pain Vomiting Hemorrhoids Gas/bloating Constipation Nausea Rectal pain Blood in stool Diarrhea Laxative use

Musculoskeletal *

Neck pain Hand/wrist pain Foot/ankle pain Shoulder pain Back pain Knee pain Hip pain Muscle weakness Osteopenia/porosis General muscle pain

Neuropsychological *

Loss of balance Poor memory Depression Dizziness Concussion Areas of numbness Quick temper Anxiety Susceptible to stress Lack of coordination Seizures

Cardiovascular *

High blood pressure Irregular heartbeat Fainting Varicose veins Cold hands/feet Swelling of ankles/feet Low blood pressure Dizziness Chest pain Blood clots Swelling of hands

Skin and Hair *

Rashes Skin cancer Eczema Ulcerations Hair loss Pimples Dryness Recent moles Itching Change in hair/skin texture Dandruff

Respiratory *

Difficulty breathing Pneumonia Asthma Cough Bronchitis Pain with a deep breath Production of mucous Smoker Coughing blood

Genito-urinary *

Frequent urination Pain on urination Unable to hold urine Blood in urine Impotency Urinary tract infections Decrease in urine flow Wake at night to urinate Urgency to urinate Kidney stones Sores/warts on genitals Other

Are you sexually active? *

Yes No

If you use birth control, which type(s) do you use? *

Are you pregnant? *

Yes No I'm trying

Average length of menstrual cycle: *

Less than 28 days 28 days More than 28 days

Age of first period? *

Date of last PAP test? *

What was the result of your last PAP test? *

Normal Abnormal

How many pregnancies? *

How many births? *

How many miscarriages? *

How many abortions? *

Submit

, Niagara Naturopathic Doctors, Physiotherapy, and Massage - Hart & Sol Integrative Healthcare