Download adult intake form (confidential)

INTAKE FORM (CONFIDENTIAL)
Borealis Naturopathic Health Center
Ashley Guité B.A. D.H.M.H.S Reg. BIE Practitioner
Date: ____________________
Name: _____________________________________________________________
(Surname)
(Given Name)
Date of Birth: DD/MM/YYYY ____________ Age: ______ □M □F
Address: ___________________________________________________________
City: ____________________ Province: _________ Postal Code: ______________
Home Phone: ______________________ Work Phone: ______________________
Emergency Contact: _______________________ Phone: _____________________
Family Physician: ____________________________ Phone: __________________
E-mail Address: ______________________________________________________
Occupation: _________________________ Number of Children if any: __________
How were you referred?
 Physician
 Self Referral
 Other
FOR FEMALE PATIENTS ONLY
Age at First Menses: _______________ Number of Pregnancies: _______________
Every disease, drug or accident leaves its mark and remains a weak point in our system.
Homeopathic treatment takes into account all of these details of the past and aims to
strengthen the system. It is important to know about all the ailments you have suffered in
the past as well as the treatments you have taken.
What problem brings you to this appointment ________________________________________________
_____________________________________________________________________________________
When did the symptoms begin? ___________________________________________________________
Are your symptoms getting worse?
 Yes
 No.
Please which of the following substances you are currently using:
□ Alcohol
□ Chewing Tobacco
How Much? ______ □ Coffee
How Much? ______ □ Recreational Drugs
How Much? ______
How Much? ______
□ Cigarettes
How Much? ______ □ Teas
How Much? ______
In the list below ALL the major illnesses so far suffered (past & present):
□ Allergy
□ Ear Infections
□ Luekaemia
□ Ringworms
□ Anemia
□ Eczema
□ Lumbar Puncture
□ Scabies
□ Appendicitis
□ Food poisoning
□ Major Bleeding
□ Asthma
□ Fungus
□ Malaria
□ Sexual Abuse
□ Backache
□ Gallbladder
□ Malnutrition
□ Sinusitis
□ Boils
□ German Measles
□ Measles
□ Small Pox
□ Bronchitis
□ Goiter
□ Meningitis
□ Cancer
□ Gonorrhea
□ Carbuncles
□ Hay Fever
□ Mumps
□ Chicken Pox
□ Headaches
□ Numbness
□ Cholera
□ Head Injury
□ Paralysis
□ Cold Sores
□ Spleen
□ Mononucleosis
□ Hepatitis
□ Septic Tonsils
□ Strep Throat
□ Stroke
□ Syphilis
□ TB
□ Pimples
□ Typhoid
□ Convulsions
□ Herpes
□ Pneumonia
□ Ulcers
□ Cramps
□ HIV/Aids
□ Polio
□ Unconsciousness
□ Diabetes
□ Hypertension
□ Prolapsed Uterus
□ Urticaria
□ Diarrhea
□ Jaundice
□ Prostate
□ Venereal Warts
□ Diphtheria
□ Kidney/Urine
□ Psoriasis
□ Whooping Cough
□ Dysentery
□ Liver Disease
□ Rheumatism
□ Worms
□ Other: _____________________________________________________________________________
_____________________________________________________________________________________
Any Serious:
□ Depression
□ Grief
□ Disappointments □ Fright
□ Mental Upset
□ Shock
□ Nervous Breakdown
Please list any necessary information about the illnesses checked: Onset (can you trace the
origin of your illness to any particular circumstance, accident, illness, or mental upset),
medications used, duration, if you completely recovered, etc:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
When are your symptoms worse?




Year Round
January
May
September
 February
 June
 October
Are symptoms better away from home?
 March
 July
 November

Yes
 No.
 April
 August
 December
If yes, when? _________________________
Please list any hospitalizations regardless of cause: ___________________________________________
_____________________________________________________________________________________
List any food allergies and reactions experienced: _____________________________________________
_____________________________________________________________________________________
List any drug allergies and reactions experienced (i.e. penicillin, aspirin, sulfa, latex, etc):
_____________________________________________________________________________________
_____________________________________________________________________________________
Describe any reaction to insect stings:
_____________________________________________________________________________________
Please list any major injuries you may have had in the past: ______________________________
_____________________________________________________________________________________
Please list any major surgeries you may have had in the past: ____________________________
_____________________________________________________________________________________
Are you currently taking ANY medications or supplements?
Medication/Supplement
For What?
(mg)
Dosage
Frequency – Amount/Day
Relationship
Father
Mother
Paternal
Grandfather
Paternal
Grandmother
Maternal
Grandfather
Maternal
Grandmother
Sister(s)
Brother(s)
Age
If deceased
age at death
Cause of Death
Diseases