289-271-2788
4161 Portage Rd, Niagara Falls ON L2E6A2
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Our Team
DR. FIGUEROA ND
DR. LETOURNEAU ND
DR. MACKIMMIE RN ND
AMY RIDDICK, Physiotherapist
TANA THOMPSON, Registered Massage Therapist
Services
Naturopathic Medicine
Fertility Check-Up Program
Fertility Enhancement Program
Intravenous Therapy "Vitamin Drip"
Tests
Physiotherapy
Registered Massage Therapy
Thermography
Patient Forms
Naturopathic Adult Intake Form
Naturopathic Child Intake Form
Naturopathic Informed Consent Form
Women's health & fertility questionnaire
Insurance Claim Consent Form
Conditions We Treat
Service Fees
Nutritional Supplements
Contact & Hours
Niagara Natural Fertility
Naturopathic Adult Intake Form
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Indicates required field
Date
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Name
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First
Last
Birth Date
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Email
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Phone Number
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Best method of contact during business hours:
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Phone
Email
Occupation
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Insurance Provider
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Emergency Contact Name
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Emergency Contact Phone Number
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How did you hear about our clinic?
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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)
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What are your chief concerns? (please list in order of importance to you)
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MEDICAL HISTORY (please list each of your medical conditions and the year of diagnosis for each condition)
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ALLERGIES (please list any allergies you have - medications, foods, pets, environmental, etc)
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VACCINATIONS/IMMUNIZATIONS RECORD (please check all that you have received):
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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:
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Do you carry an EpiPen?
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Yes
No
FAMILY HISTORY (please list each health condition and which family member(s) it relates to)
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When was your last physical exam?
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List all of your current prescription medications
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How many times have you been treated with antibiotics in the past 5 years?
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List all over-the-counter medications that you take (eg., Aspirin, Tylenol, Tums), including dose and frequency
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List all vitamins, minerals, herbs, or homeopathic supplements you are taking, including the dosage:
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PLEASE CHECK OFF ANY OF THE FOLLOWING SYMPTOMS IF THEY APPLY TO YOU:
General
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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
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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
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Indigestion
Bad breath
Abdominal cramps/pain
Vomiting
Hemorrhoids
Gas/bloating
Constipation
Nausea
Rectal pain
Blood in stool
Diarrhea
Laxative use
Musculoskeletal
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Neck pain
Hand/wrist pain
Foot/ankle pain
Shoulder pain
Back pain
Knee pain
Hip pain
Muscle weakness
Osteopenia/porosis
General muscle pain
Neuropsychological
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Loss of balance
Poor memory
Depression
Dizziness
Concussion
Areas of numbness
Quick temper
Anxiety
Susceptible to stress
Lack of coordination
Seizures
Cardiovascular
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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
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Rashes
Skin cancer
Eczema
Ulcerations
Hair loss
Pimples
Dryness
Recent moles
Itching
Change in hair/skin texture
Dandruff
Respiratory
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Difficulty breathing
Pneumonia
Asthma
Cough
Bronchitis
Pain with a deep breath
Production of mucous
Smoker
Coughing blood
Genito-urinary
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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?
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Yes
No
If you use birth control, which type(s) do you use?
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Are you pregnant?
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Yes
No
I'm trying
Average length of menstrual cycle:
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Less than 28 days
28 days
More than 28 days
Age of first period?
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Date of last PAP test?
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What was the result of your last PAP test?
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Normal
Abnormal
How many pregnancies?
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How many births?
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How many miscarriages?
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How many abortions?
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Submit