Naturopathic Adult Intake Form

HART & SOL INTEGRATIVE HEALTHCARE - (289)271-2788

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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, Twitter, or Intagram Other online source Word of mouth 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) *

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

Neuropsychological *

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

Skin and Hair *

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

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

Musculoskeletal *

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

Respiratory *

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

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

Gastrointestinal *

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

Do you carry an EpiPen? *

Yes No

ALLERGIES (please list any allergies you have and what your reaction is to the allergen) *

Do you smoke cigarettes? If so, how many and how often? *

Did you use to smoke cigarettes? If so, when did you quit? *

Do you use cannabis or other recreational drugs? If so, please specify which drug, what form, and how often you us it. *

List all of your current prescription medications *

Do you drink alcohol? If so, how much and how often? *

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 *

What is your weight? *

Reproductive *

Sperm: low count, low motility, or poor morphology Erectile dysfunction Varicocele Vasectomy Endometriosis or endometrioma Polycystic ovarian syndrome Dimished ovarian reserve Uterine fibroids or polyps Uterine malformation Painful periods Heavy periods Vaginal spotting between periods, before periods, or after periods Hysterectomy or Oophorectomy

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

Menstrual cycle length (the 1st day of your period until the 1st day of the next period) *

Are you pregnant? *

Yes No I'm trying

How many pregnancies? *

How many live births? *

How many chemical pregnancies/miscarriages/stillbirths? *

How many abortions? *

Date of last PAP test? *

What was the result of your last PAP test? *

Normal Abnormal

Genito-urinary *

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

What is your height? *

MEDICAL HISTORY (previous conditions, surgeries, reason for hospilization) *

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

Submit

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

Home
BOOK ONLINE!
Our Team
Services
Patient Forms
Conditions We Treat
Service Fees
Nutritional Supplements
Contact & Hours
COVID-19 Policy
Niagara Natural Fertility