Download “intake form” and the signed

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NATUROPATHIC & ACUPUNCTURE INTAKE FORM
By investing in Naturopathic Medicine, you have taken a major step to improving your health. As your Naturopath
and/or Acupuncturist, my goals are to help you to set a new direction towards holistic and optimal health.
Please take the time to fill out the important questionnaire contained within this package. This will help me to
understand what your goals are and what expectations you have so that we can formulate an individualized health care
plan tailored to your needs. Rest assured that all the information you share on these forms and in our interactions will
be held with the strict confidentiality.
Please remember to bring the “intake form” and the signed “informed consent form” contained in this package when
you come in for you initial visit.
Typically, your first visit is one hour long and will include a complaint-oriented physical examination. Once your
condition is assessed you will be called in for a second visit where a treatment plan will be presented to you. Your
progress will be monitored and further visits may be necessary to map out continued treatment and disease prevention.
It is also important that if you have had any laboratory testing done within the past 6 months to bring a copy of these
results with you on your first visit. If you have any difficulty gaining access to these documents, you can contact our
office and we will provide a “Release of Records” form to assist you.
Included in this package is a complete fee schedule of our services. Please take the time to review this before you come
in. At present, Naturopathic care is not covered by OHIP. However, if you have extended medical insurance, please
check with your plan to see if there is “Naturopathic Coverage” and/or “Acupuncture”, as many of the major insurance
companies do offer this.
I sincerely thank you for allowing us to be part of your health team. I look forward to getting started.
Rishma Walji, ND, RAc, PhD
Naturopathic Doctor and Registered Acupuncturist
Complete Wellness Clinic
450 Bronte South
Milton, ON L9T 8T2
905-875-2288
www.rishmawalji.com
[email protected]
www.chiropractormilton.ca
450 Bronte Street S. Milton, ON
www.rishmawalji.com
P: 905- 875-2288
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CONFIDENTIAL PATIENT INTAKE FORM
Today’s Date: ________________
Name: _____________________________________ Age: _____ Date of Birth (D/M/Y): ______________ Gender: M F
Address: _______________________________________ City: ______________________ Postal Code: ____________
Home Phone: _________________________________ Work or Other Phone: _________________________________
Profession: ______________________________ Employer: _____________________________ Full or part-time? (circle)
E-mail address: _____________________________________________________________________________________
Circle: • Married
• Single
• Widowed
Live with: • Spouse • Partner
• Divorced
• Parents
• Children
• Separated
• Friends
• Common-law
• Same Sex
• Alone
Other health care providers (name and phone number):
1. ____________________________________________________ Phone _____________________________________
2. ____________________________________________________ Phone _____________________________________
3. ____________________________________________________ Phone _____________________________________
Do you have extended medical insurance? Please specify company. ______________________________________________
Person to notify in an emergency? ___________________________ Relationship: ___________ Phone: _____________
How did you hear about our clinic? (Please circle & specify)
Internet
Phone Book
Walk-By
Advertisement: ____________________ Friend/Family Member: _____________________ Other: _________________
CURRENT HEALTH CONDITION
What health concerns brought you here today? Please list in order of importance to you:
1. ________________________________________________________________________________________________
2. ________________________________________________________________________________________________
3. ________________________________________________________________________________________________
4. ________________________________________________________________________________________________
Has anything recently changed or become worse? ________________________________________________________
__________________________________________________________________________________________________
450 Bronte Street S. Milton, ON
www.rishmawalji.com
P: 905- 875-2288
3
__________________________________________________________________________________________________
Please list the five most significant stressful events in your life. Do any of these continue to affect you?
1._________________________________________________________________________________________________
2._________________________________________________________________________________________________
3. ________________________________________________________________________________________________
4._________________________________________________________________________________________________
5. ________________________________________________________________________________________________
PERSONAL HEALTH HABITS
Height: _______ Current weight: _______ Weight 1 year ago: _______ Maximum Weight: _______ When? _______
Smoker: • Yes • No
Smoked _______Years
Alcohol use: • Yes • No
Year Stopped: ___________
Type: __________________________________ Frequency: _________________________
Recreational Drug Use: • Yes • No
Coffee: • Yes • No
Amount/day: _______
Type: _________________________ Frequency: _________________________
________ cups / day
Water: ________ cups / day
Tea: • Yes • No
Purified water: • Yes • No
________ cups / day
Tap water: • Yes • No
Do you have any food restrictions? • Yes • No If yes, please list:
__________________________________________________________________________________________________
On a scale of 1 to 10, with 10 being the highest, please rate your average STRESS level: ________________
On a scale of 1 to 10, with 10 being the highest, please rate your average ENERGY level: _______________
How many hours of sleep do you get per night? ___________ Do you wake up feeling rested? • Yes • No
Regular exercise? • Yes • No
Type: _______________________
Duration: __________ Frequency: __________
Women: Are you currently pregnant? • Yes • No • Not sure
Number of Previous Pregnancies: _________________
Type of birth control used: ___________________
Number of Live Births: _________________
If birth control pill use, how many years? ________
MEDICAL HISTORY
Do you have any allergies (environmental, dietary, medications)? • Yes • No
If yes, please list:
__________________________________________________________________________________________________
450 Bronte Street S. Milton, ON
www.rishmawalji.com
P: 905- 875-2288
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__________________________________________________________________________________________________
Please circle to indicate the conditions that pertain to you personally:
• Alcohol Abuse
• Eating Disorders
• Hepatitis
• Allergies
• Edema
• Hypoglycemia
• Anemia
• Epilepsy
• Jaundice
• Arthritis
• Eye Problems
• Joint Problems
• Asthma
• Fatigue, Chronic
• Kidney Problems
• Bladder / Urinary Problems
• Female Gynecological
Problems
• Lung Problems
• Mononucleosis
• Occupational Exposure to
Toxic Substances
• Fever
• Parasites
• Gall Bladder / Liver
Problems
• Psychological Difficulties /
suicidal / depression
• Gum / Teeth Problems
• Hay Fever
• Sexually Transmitted
Diseases (herpes,
chlamydia, gonorrhea)
• Diabetes
• Headaches
• Skin Problems
• Digestive Disturbances
• Head Injury / Serious Injury
• Thyroid
• Ear Problems
• Heart Disorders
• Ulcer
• Bleeding Problems
• Blood Pressure Problems /
Stroke
• Cancer
• Colitis
• Frequent colds, flu, sore
throats
Please indicate any serious injuries or hospitalizations; along with approximate dates:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Check any of the following that you currently use, and indicate how often you use them and/or how long you have been
using them:
Laxatives ____________________
Pain Relievers ________________
Antacids ____________________
Cortisone ____________________
Sleeping Pills _________________
Anti-Depressive ______________
Birth Control Pills _____________
Aspirin______________________
Please list all other drugs and medications (including dosage) which you are currently taking, the reason and the effect:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
450 Bronte Street S. Milton, ON
www.rishmawalji.com
P: 905- 875-2288
5
____________________________________________________________________________________ ______________
Which medications have you used in the past, the reason and the effect?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
If you take supplements please list brands and dosages of all products you are taking and the reasons for taking them:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
FAMILY HISTORY
Has a close relative (parent, child, sibling, grandparent) had any of the following:
Who?
Who?
Allergies
Bleeding Problems
Depression
Heart Disease
Arthritis
Multiple Sclerosis
Other Mental Illness
High Blood Pressure
Asthma
Kidney Disease
Drug Abuse/Alcoholism
Stroke
Epilepsy
Tuberculosis
Cancer
Diabetes
Thyroid Problems
Other? Please List:
ENVIRONMENT
Are you regularly exposed to toxins or other hazards (home, work, hobbies, etc.)? Please describe:
__________________________________________________________________________________________________
How would you describe the emotional climate of your home?
__________________________________________________________________________________________________
450 Bronte Street S. Milton, ON
www.rishmawalji.com
P: 905- 875-2288
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__________________________________________________________________________________________________
INFORMED CONSENT
Naturopathic Medicine is the treatment and prevention of disease by natural means. Naturopathic Doctors assess the
whole person, taking into consideration physical, mental, emotional and spiritual aspects of the individual. Gentle, noninvasive techniques are generally used in order to stimulate the body’s inherent healing capacity. A number of different
approaches may be used throughout the course of treatment. Treatment modalities include diet, lifestyle counselling,
clinical nutrition (including supplementation), botanical medicine, homeopathy, Traditional Asian medicine and
acupuncture, hydrotherapy, and physical medicine.
Nutritional counselling and supplements are recommended to address deficiencies, treat disease processes, and
promote health. The benefits may include increased energy, increased gastrointestinal function, improved immunity,
and general well-being.
Botanical medicine is a plant based medicine that involves the use of herbal teas, tinctures, capsules, and other forms of
herbal preparations to assist in recovery from injury and disease.
Homeopathy is a form of medicine based on the Law of Similars – that is, the use of tiny doses of the very thing that
causes symptoms in healthy people. These minute doses of plant, animal, or mineral origins are used to stimulate the
body’s ability to heal itself. Homeopathy is a powerful tool that effects healing on a physical and emotional level.
Asian medicine includes the use of acupuncture, Eastern herbs and dietary changes to eliminate disease and balance
body functions. Acupuncture refers to the insertion of sterilized disposable needles through the skin into underlying
tissues at specific points on the body. Eastern herbs may be given in the form of pills, tinctures, or decoctions (strong
teas) to be taken internally or used externally as a wash. Acupuncture is not used in children under the age of 12.
Hydrotherapy refers to the use of hot and cold water applications to improve circulation and stimulate the immune
system.
Lifestyle counselling involves identifying risk factors and making recommendations to help optimize one’s physical,
mental, and emotional environment.
During your initial visits, your Naturopathic Doctor will take a thorough case history and perform a basic/complaintoriented physical examination, and when indicated, take urine samples or perform other laboratory testing.
If you have coverage for Naturopathic Medicine, you are responsible for billing your own insurance company – we will
provide you with all of the information necessary to send your claim for reimbursement.
Even the gentlest therapies may cause complications in certain physiological conditions this depends greatly on the
individual and the extent of the illness. Some therapies must be used with caution in certain diseases such as diabetes,
heart, liver or kidney disease. It is very important, therefore, that you inform your naturopathic doctor immediately of
any disease process that you are suffering from as well as any medications (prescription or over-the-counter) that you
are taking. If you are pregnant, suspect you are pregnant, or you are breast-feeding, advise your doctor immediately.
450 Bronte Street S. Milton, ON
www.rishmawalji.com
P: 905- 875-2288
7
This is to acknowledge that I have been informed and I understand that:
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Any treatment or advice provided to me as a patient of Rishma Walji N.D. is not mutually exclusive of any
treatment or advice that I may now be receiving or may in the future receive 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 qualified to practice in Ontario
I understand that the practitioner will answer my questions to the best of her ability. I understand that the
results are not guaranteed. I do not expect Rishma Walji N.D. to be able to anticipate and explain all risks and
complications. I will rely on her to exercise judgment during the course of treatment, which she feels is in my
best interests, based on the facts known.
The treatment and therapies rendered or recommended by Rishma Walji N.D. may be different from those
usually offered by a medical doctor or other licensed health care provider.
I am responsible for making Rishma Walji ND aware of all health conditions and all other treatments that I am
undergoing. If I am or plan to be pregnant or breast feeding, I will make Rishma Walji ND aware of this
immediately.
I understand and have read the terms of the Personal Health Information and Privacy Act (PHIPA) (summarized
below, under “personal information”) and understand that Rishma Walji, ND and The Healthy Family
Chiropractic & Wellness Centre abide by the stipulations as laid out in the Act. My records are confidential
unless required by law.
I understand that my health records may be used to contribute to medical research that may help understand
disease, treatment or clinical outcomes. No personal or identifying information will be used at any time for such
purposes.
There are some risks, however rare, to Naturopathic Medicine. These include but are not limited to:
- aggravation of pre-existing symptoms,
- allergic reaction to supplements or herbs,
- pain, bruising, burning or injury from acupuncture or heat application,
- fainting or puncturing of an organ with acupuncture needles
I understand that the Naturopathic Doctor may prescribe supplements that can be purchased from our in-house
dispensary, health food store, or elsewhere of your choice. Most insurance companies do not cover supplements.
I understand that fees are to be paid at the time of consultation.
I understand that a fee will be charged for missed appointments or cancellations with less than 24 hours notice.
I have read and understand the above-stated policies and information. I intend this consent form to cover the entire
course of naturopathic treatment. I understand that I am free to withdraw my consent and to discontinue participation
in these procedures at any time.
Patient Name (please print): _____________________________________________________________________________
Signature of Patient: ________________________________________________________________
Date: __________________________
Thank you for taking the time to fill out these forms.
450 Bronte Street S. Milton, ON
www.rishmawalji.com
P: 905- 875-2288
8
I look forward to working with you on your journey to optimal health.
FEE SCHEDULE
Initial consultation (60 minutes)
$ 160
Second consultation (30 minutes)
$ 80
Extended follow-up visit (45 minutes) – only if needed, discussed in advance
$ 120
Acute consultations (15 minutes) – only for current patients, as appropriate
$ 50
Note: Any appointment cancelled with less than 48 hours notice
$ 50
Diagnostic Testing - Blood and other lab tests are available in combination with consultations, please inquire about pricing.
Fees are payable by cash, debit, visa or mastercard at the end of each visit. Any recommended supplements or homeopathics are not included in
the above fees. Please note that these fees are not covered by OHIP, but they may be covered by your extended health care plan.
Contact your employer or insurance agent to inquire about naturopathic and/or acupuncture coverage.
PERSONAL INFORMATION
Your identity will be protected at all times and a record will be kept of the health services provided. Patients may look at
their medical record at any time and may request a copy of it (may be subject to copying fee). Privacy of your personal
information is an important part of our clinic while providing you with quality health care. We understand the
importance of protecting your personal information and are committed to collecting, using and disclosing your personal
information responsibly. We will try to be as open and transparent as possible about the way we handle your personal
information.
At this office Dr. Natalie MacDonald, acts as the Privacy Information Officer. All staff members who come into contact
with your personal information are aware of the sensitive nature of the information that you have disclosed.
Our privacy policy outlines what our clinic is doing to ensure that:
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Only necessary information is collected about you;
We only share your information with your consent;
Storage, retention and destruction of your personal information complies with the existing
legislation, and privacy protection protocols;
Our privacy protocols comply with privacy legislation and standards of our regulatory body, the
Board of Directors of Drugless Therapy – Naturopathy (BDDT-N).
450 Bronte Street S. Milton, ON
www.rishmawalji.com
P: 905- 875-2288