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Doctor V
Wellness Within
101 Riel Drive (Enjoy Centre)
St. Albert AB T8N 3X4
[email protected]
www.wellness-within.ca
Phone: 780-651-7365
Welcome to Wellness Within and thank you for choosing me, Dr. V, as your Naturopathic Physician and
member of your health team! You should be proud that you have just made an important step in
improving your health. Together we will overcome the obstacles that have been preventing you from
achieving optimal health and wellbeing.
Know that I take your health very seriously and that I will do everything in my power to guide you
towards your goals. In order to help me with your particular situation please ensure that you take the
following steps prior to your initial visit:
 Complete intake form (return no later than 24 hours before your initial visit)
 Read and sign the informed consent form
 Bring any copies of previous lab test results and imaging reports (or other reports) to your
appointment (if applicable)
 Feel free to also bag up your medications and supplements and bring them to your
appointment so that we may go through those together
The initial visit will consist of an in depth review of your current and past health concerns. I will also
perform a focused physical exam based on your current needs. Once I have an understanding of what
is the primary concern, we can start our initial treatment plan, which could include:
 Ordering lab tests
 Prescribing supplements (vitamins, minerals, herbs, homeopathics, etc)
 Booking in for more advanced therapies such as acupuncture, intravenous therapy, neural
therapy, or chelation
Follow up visits will allow us to go into a more complete treatment plan, perform advanced therapies (if
indicated) and follow up on the initial treatment plan. Additional follow up visits will be determined as a
case by case basis.
I look forward to working together so that you can achieve your optimal health and wellbeing.
Sincerely,
Dr. V
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Naturopathic Medicine – Adult Informed Consent Form (2 Pages)
I, ___________________________________ (name), hereby request and consent to examination and
treatment with Naturopathic Medicine by Dr. Véronic Provencher, MSc, ND (also known as and referred
herein as Dr. V).
I understand that as a Naturopathic Physician Dr. V may include the following examination or treatment
methods, but are not limited to :
 Physical examination (including vitals, EENT, heart and lung, abdominal, musculoskeletal,
orthopedic and neurological assessments. Vaginal, testicular, rectal, prostate and breast exams
will only be administered if requested or warranted).

Common diagnostic procedures (including venipuncture, pap smears, and laboratory
evaluation of blood, urine, stool and saliva)

Botanical/herbal medicine (prescription of therapeutic plant substances which may be given in
the form of teas, pills, creams, powders, tinctures [which usually contain alcohol], suppositories,
pastes, plasters, washes or other forms)

Clinical nutrition (including food selection, diet plans, nutritional supplements)

Hydrotherapy

Counselling (including but not limited to visualization, self-empowerment techniques, mind-body
medicine and stress reduction techniques)

Homeopathic remedies (highly diluted quantities of naturally occurring substances)

Acupuncture (insertion of specialized disposable stainless steel sterilized needles through the skin
into underlying tissues at specific points on the body surface)

Moxibustion (indirect or direct burning of herbal material in the form of a loosely compacted
herb or stick)
In addition to the procedures mentioned above, I also consent to the following advanced therapies
(please initial the following):
_____ Consent to Injections: I consent to all injection procedures (including, but not limited to, vitamins,
procaine, or other solutions) rendered by Dr. V.
I understand that:
1. The procedure involves inserting a needle into various areas of the body and injecting of
substances.
2. Risks of injection therapies include but are not limited to:
a. Occasionally to commonly:
- Discomfort, severe pain, bruising, inflammation, injury and numbness at the site of
injection.
- Fatigue, dizziness, or light-headedness after the injections.
- Fainting or loss of consciousness during the procedure.
b. Extremely Rarely:
- Severe allergic reaction, anaphylaxis, infection, cardiac arrest and death.
I am aware that other unforeseeable complications could occur. I do not expect Dr. V to anticipate
and/or explain all risk and possible complications.
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________ Consent to Intravenous Therapy: I consent to all intravenous therapy procedures (including, but
not limited to micronutrient intravenous therapies and chelation) rendered by Dr. V.
I understand that:
1. The procedure involves inserting a needle into a vein and injecting the prescribed
solution.
2. Alternatives to intravenous therapy are oral supplementation and/or dietary and lifestyle
changes.
3. Risks of intravenous therapy include but not limited to
a. Occasionally to commonly: Discomfort, bruising and pain at the site of injection.
c. Rarely: Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and
injury.
d. Extremely Rarely: Severe allergic reaction, anaphylaxis, infection, cardiac arrest and
death.
3. Benefits of intravenous therapy include:
a. Injectables are not affected by stomach, or intestinal absorption problems.
b. Total amount of infusion is available to the tissues.
c. Nutrients are forced into cells by means of a high concentration gradient.
d. Higher doses of nutrients can be given than possible by mouth without intestinal irritation.
I am aware that other unforeseeable complications could occur. I do not expect Dr. V to anticipate
and/or explain all risk and possible complications.
I understand that it is my responsibility to inform Dr V immediately of the following and failure to do so
could result in unnecessary avoidable complications for which I take full responsibility:
 Notify of all current disease conditions and any changes to my current disease state
 Notify of any medication, over the counter drugs or supplements and any changes to any of
these (including new additions)
 Notify of any known allergies to drugs or other substances or any past reactions to anaesthetics
 Notify of pregnancy, suspicion of pregnancy, or breastfeeding
I understand that it is my responsibility to request that Dr. V explain therapies and procedures to my
satisfaction. I further acknowledge that no guarantee of services has been made to me concerning the
intended results of any treatment provided to me.
My signature below confirms that:
1. I have been provided ample opportunity to read this form or that it has been read to me.
2. I understand the information provided on this form and the procedures have been adequately
explained to me and thus give my oral and written consent to evaluation and treatment.
4. I intend this as a consent form to cover the entire course of treatments for my present condition
and any future conditions for which I seek treatment from Dr. V
5. I release Dr. V from any and all liability associated with, but not limited to, the procedures
mentioned herein.
6. I authorize and consent to the performance of the procedures listed herein.
7. I understand that I may withdraw my consent, in writing, at any time.
_______________________________________
Printed name of Patient
_____________________________________
Printed name of Guardian
_______________________________________
Signed name of Patient
_____________________________________
Signed name of Guardian
_______________________________________
Date
_____________________________________
Date
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NATUROPATHIC MEDICINE
CONFIDENTIAL INTAKE FORM
Person to contact in case of emergency:
PATIENT INFORMATION
Name:_______________________________________
Date:_______________________________________
Relationship:__________________________________
Phone: (home)________________________________
First Name:__________________________________
Last Name:__________________________________
(cell)_________________________________________
(work)________________________________________
Middle Initial(s):____
Preferred Name:_____________________________
How did you hear about Dr. V?________________
Have you ever been treated by a ND? □Yes□No
Home Address:______________________________
City:________________________________________
Province:_______Postal Code:________________
Phone: (home)______________________________
(cell)________________________________________
(work)_______________________________________
May we leave messages relating to your visits?
By whom:______________When:________________
Reason:______________________________________
Names of other health care providers (include
phone numbers if known):
Medical Doctor:_______________________________
Naturopathic Doctor:__________________________
Specialist:_____________________________________
Other:_________________________________________
□ Yes □ No
Email:_______________________________________
PATIENT HEALTH INFORMATION
Main health concerns in order of importance:
Date of birth:
1.___________________________________________
(D)____(M)____(Y)______Age:________
Gender:
□ male
2.___________________________________________
□ female
3.___________________________________________
Marital Status:
4.___________________________________________
□ single □ married □ divorced □ widowed
Number of kids and ages:___________________
5.___________________________________________
Ethnicity:___________________________________
Occupation:________________________________
Education: □ high school □ college diploma
□bachelor's degree □master's degree □doctoral
List any diagnoses received for any of your
medical concerns (including who provided the
diagnosis):
1.___________________________________________
degree
2.___________________________________________
Albert Health Care
#:__________________________________________
3.___________________________________________
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List all medications and supplements that you
Check which of the following you use (include
are taking (include dose and how often you
how often items are used and specify type if
take them):
necessary):
Daily
Weekly
1.___________________________________________
□ Pain Killers
_____
_____
2.___________________________________________
(type?)_________________________________
3.___________________________________________
□ Antacids
_____
_____
4.___________________________________________
□ Laxatives
_____
_____
5.___________________________________________
□ Energy Boosters
_____
_____
6.___________________________________________
□ Diet Pills
_____
_____
7.___________________________________________
□ Sweeteners
_____
_____
8.___________________________________________
(type?)__________________________________
9.___________________________________________
□ Coffee
_____
_____
10.__________________________________________
□ Recreational Drugs _____
_____
(type?)__________________________________
Allergies (food, drugs, environmental) and
□ Tobacco
_____
_____
reactions:
□ Alcohol
_____
_____
1.___________________________________________
□ Sweets
_____
_____
2.___________________________________________
□ Fast Food
_____
_____
3.___________________________________________
□ Exercise
_____
_____
4.___________________________________________
(type?)__________________________________
□ Meditation
_____
_____
Immunizations (including reactions if
applicable):
Foods or items that you currently avoid (and
____________________________________________
reason):
____________________________________________
1.________________________________________
____________________________________________
2.________________________________________
____________________________________________
3.________________________________________
Surgeries and hospitalizations (include year):
Favourite foods (or foods that you eat most
____________________________________________
often):
____________________________________________
1.________________________________________
____________________________________________
2.________________________________________
____________________________________________
3.________________________________________
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Family History (check all that apply and note
Review of Symptoms
which family member has the condition and
Height:_____________Weight:__________________
type if known):
Any major weight changes in the past year?
□ Alcoholism
______________________
□ Yes □ No
□ Allergies
______________________
If yes, how much:_____________________________
□ Arthritis
______________________
Do you have any medical alerts?_______________
□ Asthma
______________________
□ Autoimmune disease ____________________
How many hours per night do you average of
□ Blood disorder
______________________
sleep?________________________________________
□ Cancer
______________________
Do you wake rested?
□ Yes
□ No
□ Dementia
______________________
Do you wake at night?
□ Yes
□ No
□ Depression
______________________
□ Diabetes
______________________
□ Epilepsy
______________________
Check any condition that are presently causing
□ Genetic disease
______________________
problems. Type a "P" next to the conditions
□ Hay fever
______________________
which were a problem for you in the past.
□ Heart disease
______________________
General
If yes, why?____________________________
□ High blood pressure ______________________
□ __ Bleed/bruise easily □ __ Change in appetite
□ Kidney disease
______________________
□ __ Chills
□ __ Cravings
□ Mental Illness
______________________
□ __ Fatigue
□ __ Fevers
□ Neurological disorder_____________________
□ __ Night sweats
□ __ Peculiar tastes/smells
□ Obesity
□ __ Poor appetite
□ __ Poor sleep
□ Respiratory disease ______________________
□ __ Strong thirst
□ __ Sudden energy drop
□ Stroke
______________________
□ __ Sweat easily
□ __ Weight gain
□ Thyroid disease
______________________
□ __ Weight loss
□ Other
______________________
______________________
Skin and Hair
□ __ Change in hair/skin □ __ Dandruff
□ __ Eczema
□ __ Hives
□ __ Itching
□ __ Loss of hair
□ __ Pimples
□ __ Rashes
□ __ Recent moles
□ __ Ulcerations
□ __ Other:___________
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Head, Eyes, Ears, Nose, and Throat
Gastrointestinal System
□ __ Blurry vision
□ __ Abdominal pain □ __ Bad breath
□ __ Cataracts
□ __ Colour blindness □ __ Dry mouth
□ __ Belching
□ __ Bloating
□ __ Earaches
□ __ Eye pain/strain
□ __ Blood in stool
□ __ Constipation
□ __ Facial pain
□ __ Frequent colds
□ __ Diarrhea
□ __ Excessive hunger
□ __ Gum problems/sores□ __ Headaches
□ __ Gas
□ __ Heart Burn
□ __ Jaw clicks/pain
□ __ Migraines
□ __ Hemorrhoids
□ __ Indigestion
□ __ Night blindness
□ __ Nose bleeds
□ __ Nausea
□ __ Poor appetite
□ __ Poor hearing
□ __ Recurrent sore throat
□ __ Rectal pain
□ __ Vomiting blood
□ __ Ringing in ears
□ __ Sinus problems
□ __ Other:____________
□ __ Sores on lips/tongue □ __ Tooth pain
□ __ Using glasses
Genito-Urinary System
□ __ Other:______________
□ __ Blood in urine
□ __ Decrease in flow
□ __ Distinctive colour □ __ Wake to urinate
Cardiovascular and Circulatory Systems
□ __ Frequent urination □ __ Kidney stones
□ __ Angina
□ __ Calf/leg pain
□ __ Chest pain
□ __ Cold hands/feet
□ __ Fainting
□ __ Heart attack
□ __ Pain on urination
□ __ Unable to hold urine □ __ Urgency to urinate
□ __ Urinary tract infection □ __Other:___________
□ __ High blood pressure□ __ Irregular heartbeat
□ __ Low blood pressure □ __ Rapid heartbeat
□ __ Stroke
□ __ Sores on genitals
□ __ Swelling of feet
□ __ Swelling of hands □ __ Varicose veins
□ __ Other:___________
Respiratory System
Muscles, Joints, and Bones
□ __ Arthritis
□ __ Back pain
□ __ Foot/ankle pain □ __ Hand/wrist pain
□ __ Hip pain
□ __ Muscle weakness
□ __ Neck pain
□ __ Shoulder pain
□ __ Swollen joints
□ __ Other:______________
□ __ Asthma
□ __ Bronchitis
Neurological and Psychological Systems
□ __ Chronic cough
□ __ Coughing blood
□ __ Anxiety
□ __ Concussion
□ __ Difficulty breathing □ __ Pneumonia
□ __ Depression
□ __ Dizziness
□ __ Production of phlegm
□ __ Emotional
□ __ Lack of coordination
□ __ Pain with a deep breath
□ __ Loss of balance
□ __ Numbness
□ __ Other:___________
□ __ Poor memory
□ __ Quick temper
□ __ Seizures
□ __ Stress
(colour:__________)
□ __ Suicidal tendency □ __ Tremors
□ __ Worry
□ __ Others:___________
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Men
□ __ Live close to high voltage power lines
□ __ Discharge or sores □ __ Hernias
□ __ Became ill after moving to a different
□ __ Herpes
building or home
□ __ Impotency
□ __ Premature ejaculation □ __ Prostate disease
□ __ Exposed to chemicals (specify: ___________)
□ __ Sexually transmitted infection (type?)
□ __ Exposed to mold or excessive moisture
_________________
□ __ Exposed to fluorescent lighting (how
□ __ Testicular masses □ __ Testicular pain
often?____)
□ __ Other:____________
□ __ Chemically sensitive (specify if compounds
known:____________________________________)
Women
Age of first menses:
_______
Length of cycle:
_______
Date of last menses:
_______
Duration of menses:
_______
□ __ Sleep on a water bed
□ __ Use electric blanket
□ __ Use a microwave to heat foods
□ __ Have pets (what kind?____________________)
# pregnancies:________ # miscarriages:________
# births:________________ # abortions:___________
□ __ Abnormal menses □ __ Abnormal pap
□ __ Birth control (type?)_______________________
□ __ Bleeding between periods
□ __ Breast lumps
□ __ Clots (during menses)
□ __ Endometriosis
□ __ Heavy menses
□ __ Hot flashes
□ __ Mood swings
Anything else that you feel is important that has
not been covered?
_______________________________________________
_______________________________________________
Other Information
What is the most important concern that you
□ __ Nipple discharge □ __ Ovarian cysts
□ __ Pain on intercourse□ __ Painful discharge
□ __ Self-breast exams □ __ Sexual difficulties
□ __ Sexually transmitted infection type?)______
□ __ Vaginal discharge □ __ Vaginal sores
□ __ Yeast infections
Other
□ __ Other:______________
have? ________________________________________
How will you assess that this concern has been
appropriately addressed?
______________________________________________
What are you expectations of Dr. V?
______________________________________________
Environmental
What modalities are you most drawn towards:
□ __ Mercury fillings (how many?______________)
□ Herbs
□ Vitamins/Minerals
□ __ Live or work in industrial area
□ Nutrition
□ Homeopathy
□ __ Live of work near area where pesticides
□ Acupuncture
□ IV therapy
and herbicides are used (golf course, orchard, etc)
□ Neural therapy
□ Chelation
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