Download Intake Form - Dr. Keila Roesner

Keila Roesner 1
Naturopathic Doctor
Intake Form for New Patients
Thank you and welcome to Stratford Health & Wellness Center!
It is important for us to obtain an accurate history of your health to provide the best possible Naturopathic care. In order
to provide our services we ask that you please complete and sign this form at least 24 hours prior to your initial
appointment. All information gathered is treated on a strictly confidential basis, as required or allowed by law and our
privacy policy.
If your health status changes in the future, please let us know. Please feel free to ask us any questions .
Contact Information
Patient Name
Address 1
Address 2
Primary Phone
Secondary Phone
Email
Date of Birth (dd/mm/yyyy)
Emergency Contact (name and number)
Why did you choose to come to this clinic? What do you know about our approach?
What three expectations do you have from this visit to our clinic? What long term expectations do you have from working
with our clinic? What expectations do you have of me personally as your physician?
Keila Roesner ND
Dynamic health care solutions for YOUR life
Keila Roesner 2
Naturopathic Doctor
Medical Information
1. Have you had any bad reactions to medications? If yes, what type? ____________________________
2. How many courses of antibiotics have you had in the past 10 years? ____________________________
3. Please list all allergies (environmental, food, medications etc.)
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
4. Please list your top 5 health concerns.
1._____________________________________________________________________
2._____________________________________________________________________
3._____________________________________________________________________
4._____________________________________________________________________
5._____________________________________________________________________
5. Please list all current medications.
Medication Name
Dose
Since when?
How often?
Reason?
1.
2.
3.
4.
5.
Past prescriptions? ____________________________________________________
6. Please list all current supplements, vitamins and herbal medications (including self-prescribed).
Supplement Name
Dose
How often?
Since when?
Reason?
1.
2.
3.
4.
5.
Lifestyle Information
7. Current marital status (Please circle)
Married
Separated
8. a) Rate your stress level
Common-law
Single
1 2 3 4 5 6 7 8 9 10 (high)
b) What factors most contribute to your stress?
Money
Relationships
Keila Roesner ND
Widowed
Work
Health
Other
Dynamic health care solutions for YOUR life
Keila Roesner 3
Naturopathic Doctor
9. Rate your overall health
1 2 3 4 5 6 7 8 9 10 (best)
10. Rate your overall energy
1 2 3 4 5 6 7 8 9 10 (best)
11. How active is your lifestyle?
Sedentary
Moderately Active
12. Have you received any of the following (Please circle)
Traditional Chinese Medicine Homeopathy
Very Active
Naturopathic Medicine Chiropractic
13. Do you follow any specific dietary guidelines? (Please circle)
Gluten-free
Lacto-ovo vegetarian
Vegan
Religious
Other____________
14. Please answer the following as it applies to your current situation (to the best of your ability).
Glasses per
Drink water
Y N
Type (bottled, tap, filtered etc.)?
day
Drink coffee
Y N
Cups per day
Drink tea
Y N
Cups per day
Drink pop
Y N
Drink alcohol
Y N
Cans per day
Drinks per
week
Smoke or chew
tobacco
Y N
# per day
For how long?
Use other drugs
Y N
How often
What do you use, and how?
Use artificial
sweeteners
Y N
Packets per
day
Brand, type?
Chew gum
Y N
Per day
Why?
Exercise
Y N
How often?
What kinds of exercise?
Work
Y N
Hours per
week
What do you do?
Shift work?
Sleep
Y N
Cell phone use
Y N
Watch TV
Y N
Hours per
night (avg)
Hours per
day
Hours per
day
Type (herbal, green, flavored)?
Type?
Y N
Rate your job satisfaction
(1-10 is high)
Quality?
Bluetooth use?
Y N
What kinds of programs?
15. a) What behaviors or lifestyle habits do you currently engage in regularly that you believe support or benefit your
health? (please list)
Keila Roesner ND
Dynamic health care solutions for YOUR life
Keila Roesner 4
Naturopathic Doctor
b) What behaviors or lifestyle habits do you currently engage in regularly that you believe are self destructive? (please list)
16. What is your present level of commitment to address any underlying causes of your signs and symptoms that relate to
your lifestyle? (Rate from 1 to 10, 10 being 100% committed)
1 2 3 4 5 6 7 8 9 10
17. What potential obstacles do you foresee in addressing the lifestyle factors which are undermining your health and in
adhering to the therapeutic protocols which we will be sharing with you?
18. Who do you know that will sincerely support you consistently with the beneficial lifestyle changes you will be making?
19. Describe the emotional climate of your home.
20. What do you LOVE to do? Why?
Medical History
21. Date of last physical exam (dd/mm/yyyy)?
22. Date of last PAP smear?
23. Are you seeing any other health care providers? Y N
Name of Health Care Provider
Keila Roesner ND
Specialty
Address
Phone
Dynamic health care solutions for YOUR life
Keila Roesner 5
Naturopathic Doctor
24. Have you been hospitalized in the past? Y N
Type of Illness or Injury
What Happened?
Hospital
City
Year
25. List any past injuries below (car accidents, bad falls, trauma of any kind incl. physical, emotional, mental).
Type of Illness or Injury
What Happened?
26. a) Have you ever used recreational drugs? Y N
b) Do you currently use recreational drugs? Y N
City
What type, method?
What type, method?
27. Which of the following relates to your dental history? (Please circle)
Silver Fillings
White Fillings
Root Canal
Implants
Caps
26. Please indicate which of the following tests you've had in the recent past and your results.
Test
Y N
Results
Test
Y N
Sigmoidoscopy/Colonoscopy
Pregnancy
Hormone Levels
Liver Function Test
Blood Sugar
MRI
Cholesterol Panel
ECG/EKG
Complete Blood Count (CBC)
Thyroid Panel
Blood Plasma Transfusion
Mammogram
Keila Roesner ND
Year
Dentures
Results
Dynamic health care solutions for YOUR life
Keila Roesner 6
Naturopathic Doctor
27. Do you have pain? Please elaborate and indicate where.
28. Please circle all that apply as it relates to your medical history.
Childhood Illnesses
Immunization
Xrays
Chicken pox
Chicken pox
Teeth
Measles
MMR
Stomach
Mumps
DPT
Gallbladder
Rubella
Tetanus Booster
Back
Asthma
Flu Shot
Chest
Eczema
Hemophilus Influenza B
Neck
Frequent ear infections
Polio
Colon
Frequent colds
Meningococcal
Extremities
Polio
Hepatitis A
?
Rheumatic Fever
Hepatitis B
Scarlet Fever
Mantoux Test
(Tuberculosis)
Whooping Cough
?
?
29. Please answer yes or no to all concerns as they relate to your family medical history (past or present concerns).
Gr.
Concern
Mother
Father
Sibling
Children
Parent
Asthma
Cancer
Depression
Diabetes
Drug Abuse
Heart Disease
High Blood Pressure
Keila Roesner ND
Dynamic health care solutions for YOUR life
Keila Roesner 7
Naturopathic Doctor
Infertility
Lung Disease
Mental Health
Concerns
Kidney Disease
Osteoporosis
Stroke
Suicide (incl. attempts)
Thyroid Disease
Other?
Based on your family's history, do you have any particular health concerns?
30. Women's Health
Are you currently
pregnant?
Y N
Do you have
regular PAP
smears?
Y N
Is your period
regular?
Y N
Do you get PMS?
Y N
If yes, how
often?
Are you postmenopausal?
Y N
Date of last
period:
Have you ever
been pregnant?
Y N
Have you ever
had any of the
following
concerning your
breasts?
Pain
Lumps
Infections
Do you
experience
vaginal
infections?
Never
Rarely
Frequently
How many months?
Last PAP:
Age of first period:
Regular
# of pregnancies?
Keila Roesner ND
Any
abnormal
PAPs?
Y N
Avg. length of flow (days):
Severe
How many?
Avg. length of cycle
(days):
Symptoms?
Births?
Miscarriages?
Cysts
Nipple
discharge
Abortions?
Dynamic health care solutions for YOUR life
Keila Roesner 8
Naturopathic Doctor
Do you get
bladder
infections?
Never
Rarely
Frequently
Men's Health
Do you get blood work done regularly?
Y N
Do you have difficulty
urinating completely?
Do you have regular prostate exams?
Y N
Last exam date:
STIs
Testicular pain
Y N
How many times do you get up from
your sleep to go to the bathroom?
Have you ever had any of the following?
Hernia
Sores
Discharge
31. Any other concerns that we should be aware of?
Keila Roesner ND
Dynamic health care solutions for YOUR life
Keila Roesner 9
Naturopathic Doctor
Diet Diary
Breakfast
Lunch
Dinner
Snacks/Other
Symptoms
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Keila Roesner ND
Dynamic health care solutions for YOUR life
Keila Roesner 10
Naturopathic Doctor
Informed Consent
Naturopathic Doctors must obtain informed consent prior to beginning any treatment
in order to make sure that you are aware of any risks and/or side effects to treatments.
Dr. Keila Roesner ND uses the following treatment modalities in her practice: acupuncture, botanical medicine,
homeopathy, diet and nutritional counseling, lifestyle counseling and physical medicine.
Although Naturopathic Medicine is generally very safe and effective for most people, even the gentlest of therapies may
have certain complications in some physiological conditions such as in pregnancy and lactation, in young children or in
those taking multiple medications. Some therapies must be used with caution in certain diseases including but not limited
to: diabetes, heart/liver/kidney disease. It is very important that you inform Dr. Keila Roesner ND immediately if any of
the above applies to you. Because each individual may respond differently to treatment, Dr. Keila Roesner ND may not be
able to anticipate and explain ALL risks and complications.
There are some risks to treatment by Naturopathic Medicine, including but not limited to: aggravation of pre-existing
symptoms, allergic reactions to supplements or herbs, pain/bruising/injury from acupuncture, fainting or injury to an
organ with acupuncture needles and bleeding/bruising from acupuncture needles. Dr. Keila Roesner ND will take
precautions to minimize these risks.
I understand that all information provided during my visit is strictly confidential. Information may only be released upon
my written request or as required by law.
I acknowledge that I have the opportunity to discuss with Dr. Keila Roesner ND the nature and purpose of naturopathic
treatment in general and my treatment in particular.
I consent to the Naturopathic treatments offered or recommended to me by Dr. Keila Roesner ND. I intent this consent to
apply to all my present and future naturopathic care.
____________________
Patient Name
_______________________________
Signature of Parent/Guardian (if applicable)
____________________
Witness Name
_______________________________
Witness Signature
Keila Roesner ND
____________
Date
____________
Date
Dynamic health care solutions for YOUR life