Corehealthmuskoka.com



Welcome to the ClinicIn order to serve you as efficiently and effectively as possible, please complete the enclosed forms prior to your appointment. If you have any questions please feel free to call the clinic.We respectfully request 72 hours notice in the event that you cannot keep your first appointment. The first consultation can involve upwards of 1.5 – 2hours time, depending on the individualPlease bring to your appointmentThis completed form.Any remedies (vitamins, minerals, homeopathics, herbs, and drug etc) you are currently taking.Any relevant test results already completed.First morning urine sample in a clean, disposable containerAs a large number of patients of this clinic have environmental/chemical sensitivities the offices are perfume-free zones. We would ask that you refrain from wearing any perfumes on your appointment.Your appointment is on Full payment is to be made at the time of your visit. Cash, Cheque, Debit, Visa or Mastercard are all acceptedtender for transactions.Full Name Date of Birth yymmddAddress City Postal Code Phone Number ()- Cell Phone Number _________________________________Email______________________________________________Occupation: Emergency Contact RelationshipPhone Number Marital Status:singlemarriedwidowed Number of Children:ages: If the patient is a child, give parents names: Mother___________Father HOW DID YOU LEARN OF OUR OFFICE:FriendRelativeHealth Care Professional Name: HAVE YOU HAD PREVIOUS NATUROPATHIC CARE:If yes, when? With whom? Major health concerns in order of importance142536PRESCRIPTION medications you take on a regular basis, including birth control and allergy shotsName of prescription medicationDoseFrequencyDurationSide effects, if anyUse the back of this sheet if additional paper is necessaryNON-PRESCRIPTION medications you take on a regular basis, including vitamins/minerals/herbsName and brandDoseFrequencyDurationSide effects, if anyUse the back of this sheet if additional paper is necessaryHave you had all standard vaccinationsYESNOHave you had: Flu Vaccine YES NO Have you had: HPV Vaccine YES NO Please list any medications/immunizations that you stopped because of side effects or allergic reactionName of MedicationType of side-effect/reactionAgeYearAre you following any special dietsOther treatments you are currently following (massage, rehab, diets etc)List all surgeriesList all major injuries, accidents, or fallsList all hospitalisationsFamily History: In your parents, siblings or grandparents is there a history of:?Anemia??arthritis??eczema??glaucoma??seizure or epilepsy??thyroid problems?hypertension??heart disease??high cholesterol??diabetes??asthma??alcoholism?psychiatric illness??cancer??other Chronologic account of persistent, recurrent or significant illness or injuries, surgical procedures etc(please provide a summary of your major health issues in the order in which they occurred in your life)YearNature of health problemRemarks (medications, test, surgery etc) Have you had a birth defect? o Yes o No If yes, explain ____________________________________________________________________________________ Have you had a birth injury? o Yeso No If yes, explain ____________________________________________________________________________________Your usual health is:??Excellent??Good??Fair??PoorNumber of times per week you exercise at least 30 min:???0??1-2??3-5??over 5 times/weekRecord the number of servings you consume daily of each of the following:coffee decaf coffee regular tea herbal tea soft drinks milk juice water beer spirits other Have you linked any symptoms with drinking any of them? If so which symptoms?Do you eat fish? yes noOn average, how many days per week?Type(s) of fish eaten (eg. tuna/salmon etc.)? Please list any foods or beverages that do not agree with you ( eg. stuffy runny nose, heartburn, bloating, diarrhea, sleepiness, difficulty thinking or concentrating, etc.) or cause allergic reactions ( eg. hives, other rashes, shortness of breath, wheezing, anaphylaxis, etc.):List foods/drinks thatare a problemWhat problem(s) do theygive you?Approximately how often do you eat / drinkthem?NeverOccasionallyDailyMorePHYSICAL INFORMATIONWeight nowIdeal weightWeight 1 year agoHeightMaximum weightDate of last physical examinationList any foods/beverages that you crave or that help you to feel better:List foods/drinks thatyou craveWhat problem(s), if any, dothey give you?Approximately how often do you eat / drinkthem?NeverOccasionallyDailyMoreReactions/Sensitivities/Allergies to natural substancesAre you allergic to pollen, animal dander, dust, mites, or moulds?yes no (please specify) Have you ever had allergy tests?yesnoReactions/Sensitivities/Allergies to Synthetic SubstancesHave you ever had symptoms you linked with exposure to any synthetic (man-made) chemical at a level that did not seem to bother most people (eg paints, perfumes, cosmetics, diesel exhaust, tar etc), if yes please explain belowMan-made chemicalSymptoms linked with exposurePresently affectedIn the PastDENTAL AMALGAMSHow many mercury fillings do you have?How many gold fillings/caps do you have?How many mercury fillings have you replaced?Do you have any other metal in your mouth?SMOKING HISTORYDo you currently smoke tobacco? yes no If yes how many/day:For how many years If you smoked previously when did you quit? How many/dayFor how many years TRAVEL ILLNESSES: Have you ever experienced significant illness when travellingIllnessLocationAgeYearCOMMUNICABLE DISEASE: Check items which apply. Do you now or have you ever had?Measles o YES o NO Rheumatic Fever o YES o NOGerman Measles o YES o NOPolio or Meningitis o YES o NOMumps o YES o NOTuberculosis o YES o NOChicken Pox o YES o NOValley Fever o YES o NO Whooping Cough o YES o NOInfectious Mononucleosis o YES o NODiphtheria o YES o NO Syphilis o YES o NOInfluenza o YES o NOGonorrhea o YES o NOScarlet Fever o YES o NOOther: ____________________________________________Studies: Check items which apply: In the past 10 years have you had any of the following studies:YesNoIf yes, when?X-ray of the sinusesX-rays of the chestX-rays of the stomach, gallbladder or colonX-rays of the teeth (dental examination)Scans of the whole body, bone or brainElectrocardiogramHearing testsBlood or Urine testsTuberculin Skin Test (TB skin test)Prostate ExaminationMammographyPsychological: Check items which apply:o feel groggy o fainting spellso often break out in cold sweatso short attention spano blackoutso profuse sweatingo unable to reasono worried by little thingso cry ofteno unable to concentrateo sweats with anxietyo feel insecureo forgetfulo frustrationo paleo startled by sudden noiseso psychiatric careo restless legso shakyo amnesiao considered clumsyo considered a nervous persono had shock therapyo unable to coordinate muscleso frequently keyed up/jitteryo go to pieces easilyo have difficulty falling asleepSTRESSES: Do you currently face or have faced, any of the following stresses (please check if yes)yesYearyesYearLoss of someone closeDivorceIllness of someone closePregnancyLoss of jobAlcohol/Drug addictionChange of jobAlcohol/Drug addiction (in someone else)Change of workplacePhysical abuseA moveEmotional abuseMarriageSexual abuseSeparationOther (please specify)SleepHow many hours of sleep do you get? ________________________________Do you wake up rested?o YESo NODo you wake in the middle of the night?o YESo NO If yes, what time? ________________Do you recall dreaming?o YESo NODo you have recurrent dreams?o YESo NOEnvironment: Check the items that apply:Do you live in an apartment?o YESo NOHow old? ______________________Do you live in a house?o YESo NOHow old? ______________________Other type of housing: mobile home, farm, ect. Be specific: _________________________________________Is there a garage attached?o YESo NOIs there an abundance of vegetation immediately around your home?o YESo NODoes your home tend to get dustier than other homes?o YESo NODoes your home have a basement?o YESo NOHave you ever noticed mold or mildew in your home?(basement, bathroom, closet, windowsills,ect)o YESo NOPOLLEN: Check items which apply:o worse outdoorso redness of eyeso worse on windy dayso worse on clear sunny dayso watery eyeso worse outdoors from 7am to 11amo itchy eyeso air conditioning helpsDoes it flare when going from an air conditioned room to open air? o YESo NODoes the cool air of air conditioning increase your symptoms?o YESo NOAre nasal and eye symptoms both present?o YESo NODUST: Check items which apply: o worst indoorso dusting or sweeping increases symptomso better outdoorso sinus troubleo productive cougho frequent coldso worse in damp airo purulent secretionso intermittent feverFlare shortly after going to bed?o YESo NOSymptoms accentuate on waking?o YESo NOSymptoms recur or increase each year with the return of cold weather?o YESo NODo you experience definite nasal symptoms:With little or no itching of your eyes?o YESo NOWith itching of your eyes?o YESo NOAre your symptoms worse when the furnace goes on for the year?o YESo NOOther? _______________________________________________________________________________________________________MOLD: Check items which apply:o worse outdoors between 4:30 and 8:30pmo worse after sundowno better in your houseo worse in a certain roomo cool evening air increases your symptoms which room? ____________________________o worse in damp placeso worse when mowing or playing on grasso flare in the basemento worse in a certain homeo worse on windy dayso worse in your house, but not in otherso Other: _________________________________________________________________________________________PILLOW: Check items which apply:o Feathero Synthetico Downo Foam Rubbero Other_____________________________MATTRESS: Check items which apply:o water bedo conventionalo box springo cottono futon (cotton/foam)o other: _____________________________________________o foam rubbero plastic coveredo spouse/roommate’s mattress: ________________________________________BLANKETS: Check items which apply:o woolo quilto cottono synthetico spouse/roommate’s blanket: __________________________ANIMALS OR PETS: Check items which apply:o dogo cato birdo fisho rabbitso horse (own/ride)o hamstero guinea pigo cattleo otherAnimals in house?o YESo NOAnimals in bedroom?o YESo NOPLANTS: Check items which apply: Do you have indoor plantso YESo NOIf yes, how many and where?___________________________________________________________________________________________________________________FLOORING: Check items which apply:- Carpet/rugs:o cottono woolo synthetico foamo felt o straw/fiber padding- Tile:o vinylo marbleo terrazzoo ceramicAPPLIANCES: Check items which apply:Stove:o Gaso Electric Exhaust fan? o YES o NODryer:o Gaso ElectricRefrigerator:o Gaso ElectricWater Heater:o Gaso ElectricLocation: ____________________________________________CLIMATE CONTROL SYSTEMS: Check items which apply: Heating:o Gas forced airo Floor Furnaceo Oil Forced airo Gas or Kerosene heating unito Radiator steam/hot water heato Fireplaceo Electric baseboard or panelo Wall furnaceo Space heater (vented/ unvented)o Other: _____________________________________________________________________________Air Conditioning:o Window Filters:o Electrostatico HEPAo Fume controlo Carbono CentralOther: _______________________________________________________________________________ FURNISHINGS: Check items which apply:Upholstery:o cottono syntheticCushions:o foamo cottono syntheticWindow Coverings:o metal o woodeno synthetico cottonCHEMICALS: Check items which apply:Do you use strong chemicals (ie; disinfectants, bleaches, oven and drain cleaners) in your home?o YES o NOIf yes, name them:_______________________________________________________________________________________Do you use floor & furniture wax and wax remover:o Yeso NODo you use pesticides in your home?o YESo NOIf yes, name them: ______________________________________________________________________________________Do you, or have you used a lawn care company?o YESo NOIf yes, name the company: _______________________________________________________________________________ When was the last time? _________________________________________________________________________________How often do you have the treatments? ___________________________________________________________________Do you regularly have your home treated for insects?o YESo NOIf yes, name the company and list the specific name of the chemical _________________________________________Have you had your home treated for termites?o YESo NOIf yes, when? __________________________________________________________________________________________List the product used: ___________________________________________________________________________________ELECTROMAGNETIC FORCEDo you live near a power generating station?o YESo NOIf yes, how near?o 150 meters or lesso 3-5 kmo 10kmo 15kmDo you live near an electric distribution substation?o YESo NOIf yes, how near?o 150 meters or lesso 3-5kmo 10kmo 15kmDo you live near high voltage electrical transmission lines?o YESo NOIf yes, how near?o 150 meters or lesso 3-5kmo 10kmo 15kmIs there a power transformer near your home?o YESo NOIf yes, how near?o 150 meters or lesso 3-5kmo 10kmo 15kmDo you live in direct line of a television transmitter?o YESo NOIf yes, how near?o 150 meters or lesso 3-5kmo 10kmo 15kmDo you live near a microwave tower?o YESo NOIf yes, how near?o 150 meters or lesso 3-5kmo 10kmo 15kmDo you notice symptoms produced from these?o TV transmittero Generating Stationo Electric Lineso Transformero Electric distribution substationo Microwave towerList symptoms produced, in order of severity:TV transmitter1.____________________2.____________________3.____________________Electric Lines1.____________________2.____________________3.____________________Transformer1.____________________2.____________________3.____________________Generating Station1.____________________2.____________________3.____________________Electric Substation1.____________________2.____________________3.____________________Microwave tower1.____________________2.____________________3.____________________What type of electric lights do you have?o incandescento fluorescento full spectrumDo you notice any symptoms from your lighting?o YESo NOIf yes, list the symptoms in order of severity:1.____________________2._____________________3.____________________On what type of equipment do you prepare your food?o gaso electrico microwaveDo you notice any symptoms when near the microwave oven?o YESo NODo you notice any symptoms from exposure to the TV?o YESo NODo you have a TV antenna on your home?o YESo NODo you have cable television?o YESo NODo you work with computers &/or electric typewriters?o YESo NODo you use electric blankets?o YESo NOIf you experience symptoms, please list in order of severity:Microwave1.____________________2.____________________3.____________________Antenna1.____________________2.____________________3.____________________Cable1.____________________2.____________________3.____________________Computers1.____________________2.____________________3.____________________Weather Changes1.____________________2.____________________3.____________________Electric Blankets1.____________________2._____________________3.____________________Do weather changes cause a change in your mental or physical health?o YESo NOExplain:______________________________________________________________________________________ INHALANT AND CHEMICAL EXPOSURE: Check your occupation exposureso Office Workero Work around cosmeticso Professional workero Factory workero Work around fumeso Farm workero Work in extreme heato Work in extreme coldo Work indoorso Salespersono Construction workero Paintero Hospital workero Teachero Work with animalso Other: ______________________________________________________________________________________________Check if exposed to: DOUBLE CHECK if you have symptoms from:o Dusto Fireplaceo Old homeo Marshy areao Desert areao Woody areao Prairieo Tobacco smokeo Linoleumo New carpeto Old carpeto Rugso Wooden floorso Diesel fumeso Gasoline fumeso Photocopy papero Varnisho Solventso Lacquero Furniture polisho Floor waxo Incenseo Mothballso Disinfectantso Plastico Dyeso Paintso Turpentineo Dry cleaningo Pesticideso Herbicideso Grain dusto Mildewo Dog insideo Cat insideo Bird insideo Other pets insideo Taro Rubbero Chemicalso Potted plantso Cosmeticso Nail polisho PerfumeList 4 symptoms from these exposures in order of severity:1.____________________2.____________________3.____________________4.____________________Health QuestionnaireEYES, EARS, NOSE, THROATo Eyes sensitive to bright lighto Discharge from eyeso Eyes red or itchyo Puffiness or dark circles under eyeso Cataractso Wear corrective glasseso Get boils or styeso Ear discharge or ears stuffed upo Ear infection- past or presento Runny noseo Nose bleedso Post nasal dripo Sinusitis/rhinitiso Hay fevero Allergieso Breathe through moutho Loss of smello Loss of tasteo Throat infectionso cold sores, fever blisterso Inflamed or bleeding gumso Mucous in throato Swollen tongueo Frequent sore throatso Swollen glandso Metallic taste in your moutho Burning sensation on your tongueDIGESTIVE SYSTEMo Nauseao Excessive salivationo Mouth too dryo Pain on swallowingo Get full quicklyo Don’t get full quicklyo Poor appetiteo Excessive appetiteo Chronic stomach paino Stomach pain when emotionally upseto Relief of stomach pain by drinking carbonated beverageso Relief of stomach pain by drinking milko Excessive burpingo Fullness for extended time after mealso Bloatingo Abdominal crampingo Stomach upsets easilyo History of heartburno History of ulcers or gastritiso Known food allergieso Fatigue after eatingo Excess gaso Digestion very rapido Hemorrhoidso Frequent need for laxativeso History of constipation and diarrheao History of diarrheao Roughage and fiber cause constipationo Dependency on antacidso Intolerance to greasy foodso Headaches if meal missedSTOOLo Light coloured stoolo Black stoolo Hard stoolo Thin stoolo Poorly formed stoolo Painful to pass stoolo Blood in stoolo Undigested food in stoolo Mucous in stoolNumber of bowel movements/day:LIVERo Jaundiceo Hepatitis A, B, or Co High total cholesterolo Cholesterol level above 5.2 mmol/Lo Low HDL cholesterolo Strong smelling urineo Triglyceride level above 2.3mmol/Lo Trouble waking up in morningo Sugar causes irritability & mood swingso anemia unaffected by irono Work with hazardous chemicalso Periodic constipationo Sensitive to exhaust fumes, smoke, smog & petrochemicalso Can’t tolerate much exerciseo Dizziness upon standingo Migraine headaches CARDIOVASCULARo Shortness of breatho Chest pain while walkingo Heaviness in legso Calf muscles cramp while walkingo Heart pounds easilyo Feel jitteryo Heart misses beats or has extra beatso Swelling of feet and ankleso Pain in left armo Exhausts with minor exertiono Bright red noseo Cold hands and feeto Numbness in extremitieso Poor concentrationo Ringing in earso Pain on waking, in back of head and necko Dizzinesso Vertigoo Fatigue easilyo Bruise easilyo Blushing with no apparent causeo Varicose veinso Chest Painso Dizziness when standing suddenlyo Loss of vision when standing suddenlyo Anginao Heart murmuro Abnormal EKG(electrocardiogram)o Night sweatso Need to drink coffee to get startedo Impatient, moody, nervouso Boils and leg soreso Cuts take a long time to healo Overweighto Feel energized from exerciseo Failing eye sighto Family history of diabeteso Sugar in urinePULMONARYo Persistent cougho Difficulty breathingo Coughing up bloodo Coughing up phlegmo Pain around ribso Shortness of breatho Rattling mucous when breathingo Chronic lung congestiono Sensitive to smogo Infections settle in lungso Work around people who smokeo Asthmao Hay fevero Bronchitiso Difficulty breathingo Slow to recover from cold or fluBLADDERo Frequent urinationo Rarely need to urinateo Difficulty passing urineo Urinate when you cough or sneezeo Painful/burning when passing urineo Dripping after urinationo Can’t hold urine/stress incontinenceo Rose coloured(bloody) urineo Cloudy urineo Strong smelling urineo History of bladder infectionso Have used antibiotics for urinary tract infections If yes, when did you last use them? ____________________________________________________________________MALES ONLYo Difficulty urinatingo A sense of bladder fullnesso Pain or burning while urinatingo Increased straining with smaller and smaller amounts of urine passedo Wake up to urinate during at nighto Dripping after urinationo Lack of sex driveo Ejaculation causes paino Premature ejaculationo Pain/coldness in genital areao Infertileo Varicose veins of scrotumo Low sperm counto Discharge from peniso Swollen genitalso Swelling in groino Sexually transmitted disease(gonorrhea, syphilis, herpes, other)FEMALES ONLYo Menstrual paino Monthly weight gaino Depressiono Mood swingso Nausea and/or vomitingo Anxietyo Leg cramps and tendernesso Asthma attackso Headacheso Angero Low backacheo Vaginal dischargeo Missed periodso Over age 15 and have not begun menstruationo Unable to get pregnanto Low abdominal paino Increased urinary frequencyo Dull ache radiating to low back or legso Pelvic sorenesso Diarrheao Abdominal bloatingo Have to lie down on first 1 or 2 days of periodo Craving for sweetso Insomniao Light scanty blood flowo Pain during period is progressively getting worsto Vaginal bumps & soreso Pain and cramps without blood flowo Heavy menstrual bleedingo Pubic area soreo Breast lumps/breasts painful/sore to toucho Ovarian cysts/uterine cystso Pain in ovarieso Water retention/swollen feelingo Premenstrual breast pain or discomforto Mother used D.E.S.(hormones) while pregnanto Recent Pap smear abnormalo Family history of breast cancero Hot flasheso Night sweatso Hysterectomyo Sweating throughout dayo Dryness of skin, hair and vaginao Painful intercourseo Vaginal painForm of birth control(if used) ____ none ___pill ___IUD ___sponge ___diaphragm ___foam ___condom ____ cervical ___mucous ___temperature ___other Age of first menstruation?_____________________Number of pregnancies? ______________________Miscarriages? ________________________________ Date of last menstrual period?_________________________________MUSCULOSKELETALo Painful fingers, arms, handso Bones sore/painfulo Bone losso Calcium depositso Bone deformityo Recent bone fractureo Have osteoporosis/osteomalaciao Muscle crampso Leg cramps at nighto Stiffness only in the morningo Stiffness all overo Unable to sit straighto Pain in neck and /or shouldero Swollen knees/elbowso Low back paino Athletic injuryo Bursitis/tendonitiso Joint paino Slipped disc/herniated disco Loss in heighto Injure easilyNEUROLOGICALo Loss of balanceo Trembling handso Loss of grip strengtho Limbs feel too heavy to hold upo Tingling pain sensationo Convulsionso In-coordinationo Nervousnesso Accident proneo Need for 10-12hrs sleep per nighto Loss of muscle toneo Nightmareso Can’t fall asleep/insomniao Leg cramps/restless legs at nighto Intense dreamso Awake frequently throughout nighto Can’t fall back to sleep after wakingo Restless/uneasy sleepero Are you considered nervous/jitteryo Sleep walko ShinglesSKINo Unexplained rasheso Red colour flusheso Excessive itchingo Rough skino Dry skino Acne(pimples)o Hives from food or drugso Moist oily skino DandruffFOODSo Gain weigh on low calorie dietso Usually add salt to your mealso Chew gum frequentlyo Usually eat lite salt, a salt substituteo Usually avoid butter/eat margarineo Usually skip breakfast or luncho Are you on a special diet for any health problemo Do you eat eggso Usually avoid raw vegetableso Eat cheese regularlyo Avoid sugaro Do you eat many soya productso Are you vegetariano Snack on sweetso Eat bakery goods daily (donuts, cakes, cookies)o Often eat canned fruit/vegetableso Often eat white flour foods (pasta/bread)o Gain weight easilyServings of fruit per day ____________Servings of vegetables per day _________________Declaration and Consent to TreatName Date This is to acknowledge that I have been informed and I understand that: OHIP does not cover Naturopathic services; therefore fees for Naturopathic services and all supplements are the responsibility of the patient, payable in full, at the time of the appointment.We are required by our licensing board to perform a basic physical examination on each new client. This will be adhered to, unlessthis office accepts the examination of the referring practitioner who sends a full report and that report has a specific request(i.e.: ifyour dentist refers you for testing of dental materials, then a written request from the dentist must be forwarded)With the number of clients we thoroughly interview, assess and treat, timing is crucial. For the convenience of our clients, and forthe orderly and efficient operation of our clinic, we endeavor to keep scheduled appointments on time; however, complications and emergencies do arise and in these circumstances, we appreciate your patience and understanding.I have read all the foregoing information and that I understand that the ultimate responsibility for my health is my own.I will be seeing a Naturopathic Doctor not a Medical DoctorThe Naturopathic Doctor(s) at the Wellness Clinic work within the Naturopathic scope of practice.Any treatment or advice given to me as a patient of the Naturopathic Wellness Clinic is not mutually exclusive from any treatment or advice that I may receive now, or in the future, from another licensed health care provider.I am at liberty to seek or continue medical care from a physician or surgeon or other health care provider.No employee, agent, or anyone else under the Naturopathic Wellness Clinic’s direction or control is suggesting or recommending to me to refrain from seeking or following the advice of another health care provider.The treatment and therapies rendered or recommended by the Naturopathic Wellness Clinic may be different than those usually offered by a medical doctor or other licensed health care provider.I agree to abide by the financial policies as outlined and I accept full responsibility for any fees incurred during care and treatment. I agree to fully discharge this responsibility at the time of the visit unless prior arrangements have been made. 9. I understand that my appointment time is reserved for me and the clinic requires a minimum of 24 hours notice for cancellation or change (72 hours for new patients and special appointments), otherwise I will be billed for the the full fee for missed appointments. I declare that I have received a full and complete explanation of the treatment of services that I may receive at the Naturopathic Wellness Clinic and hereby authorize consent to treatment.Signature ................
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