Confidential Adult Case History

Confidential Adult Case History Please help me to understand your health needs by carefully completing this intake form. All information is strictly confidential.

Patient Information:

Name: ______Gender: ______(First) (Last) Date of Birth: ______Age: ______Care Card # (PHN): ______(Month) (Day) (Year) Contact Information: Phone #: ______Alt. Phone #: ______Home Address: ______City: ______Province: ______Postal Code: ______E-mail: ______Relationship Status: ______Emergency Contact Name: ______Phone: ______Relation: ______Do you have a family doctor? Yes ☐ No ☐ Doctor/Clinic Name: ______How did you hear about us? ______

Current Health: Do you have any known allergies ? Yes ☐ No ☐ If yes, please list: ______Height: ______Weight: ______lbs. Any recent weight changes? ______Your main health concerns in order of importance:

1. ______4. ______1. ______5. ______2. ______6. ______Please list any medications and natural supplements you are currently taking, with dosages: ______

Diet and Lifestyle: Please describe a typical day of eating for you: Breakfast: ______Lunch: ______Dinner: ______Snacks/Beverages: ______

How often do you consume the following? (daily, weekly, monthly, yearly, in the past, never) Alcohol? ______Cigarettes? ______Marijuana? ______Recreational drugs? ______Coffee? ______Pop? ______Sugar? ______

#404 – 1200 Lonsdale Avenue | North Vancouver, BC V7M 3H6 | P: 604-987-1418 | F: 604-960-9648 Dr. Gurinder Dayal, ND | lonsdalenaturopathic.com Past Medical History: Please list all past hospitalizations, surgeries, accidents and major illnesses: ______Year: ______Year: ______Year: ______Year: ______

Family Medical History: Has anyone in your immediate family been diagnosed with any of the following?  Autoimmune condition  Diabetes  Heart Disease  Cancer: type(s) ______ Mental illness  Thyroid disease  Other ______

Overview of Body Systems: Please check any boxes that are current or recurrent concerns: General  Irregular moles  Pain during intercourse  Fatigue  Hair loss  Sexually transmitted  Weight loss Throat  Weak/brittle nails infection  Night sweats  Swollen/enlarged glands  Low/high sex drive  Headaches  Sore throat  Birth control use  Sweat easily  Hoarseness Musculoskeletal  Numbness or tingling  Feeling of lump in throat  Muscle pain/spasm  Lightheadedness  Difficulty swallowing where? ______Emotional  Dizziness  Thyroid condition  Chronic Injury  Depression  Fainting  Joint pain  Irritability/quick temper Respiratory  Bone pain  Anxiety Eyes  Shortness of breath  Abuse of any form  Eye pain  Chronic cough Gastrointestinal  Light sensitivity  Coughing blood  Low appetite Male  Hearing loss/impairment  Pneumonia/bronchitis  Heartburn/reflux  Hernia  Visual loss/impairment  Asthma  Gas  Testicular pain/mass  Blurred vision  Allergies (pollen, pets)  Blood in stool  Difficulty with erections  Undigested food in stool  Prostate problems Ears Blood  Diarrhea  Ear aches/infections  Easy bruising  Constipation Female - Gynecologic  Ringing in ears  Anemia  Rectal pain  Menopause  Hemorrhoids  # Births ____ Nose & Sinuses Cardiovascular  Bowel movements:  # Pregnancies ____  Loss of smell  High/low how often: ______ # days menstruating  Nosebleeds blood pressure ____  Sinus infections  Heart flutters/skips Urinary  # days in cycle ______ Post-nasal drip  Chest pain  Pain on urination  Date of last PAP _____  Chronic congestion  Swelling of limbs  Frequent urination  Recurrent yeast  Murmurs  Recurrent urinary infections Mouth  Varicose veins infections  Vaginal discharge  Loss of taste  Urinary incontinence  Bleeding between  Tooth problems Skin, Hair and Nails  Waking to urinate periods  Mercury fillings  Eczema/Psoriasis  Decrease in urine flow  Excessive/light flow  Sores on lips or mouth  Rashes/Hives  Kidney stones  Painful periods/cramps  Painful/Bleeding gums  Itching  Missed Periods  Sores on/painful tongue  Acne, boils Sexual

#404 – 1200 Lonsdale Avenue | North Vancouver, BC V7M 3H6 | P: 604-987-1418 | F: 604-960-9648 Dr. Gurinder Dayal, ND | lonsdalenaturopathic.com Female - Breast  Nipple discharge Neurological  Headaches/Migraines  Breast pain / tenderness  Pain during intercourse  Poor memory  Breast lumps  Difficulty concentrating

#404 – 1200 Lonsdale Avenue | North Vancouver, BC V7M 3H6 | P: 604-987-1418 | F: 604-960-9648 Dr. Gurinder Dayal, ND | lonsdalenaturopathic.com Consent to Naturopathic Treatment Naturopathic examination includes: physical and clinical diagnosis, traditional Chinese medical diagnosis and lab work. Therapeutic procedures include: homeopathy, spinal adjustment, botanical medicine, acupuncture, manual muscle therapy, cranio-sacral therapy, clinical nutrition, lifestyle counseling, and Inter-Muscular Injection Therapy.

Occasionally, complications may arise. Any procedure intended to help may have complications. While the chances of experiencing complications are minimal, it is the practice of this clinic to inform our patients about them. These complications may include, but are not limited to: soreness, inflammation, soft tissue injury, dizziness, burns, bruising, stroke, and temporary worsening of symptoms. More serious complications are extremely rare.

I have read and understand the above statements regarding potential treatment side-effects. I also understand that there is no guarantee or warranty for a specific cure result.

I understand the visit costs for Naturopathic treatment are as follows:

Initial Adult Consultation $150.00 Initial Student/ Senior (65+) Consultation $140.00 The Initial visit is 40 minutes with Dr. Dayal

Subsequent Adult Consultation $75.00 Subsequent Student/ Senior Consultation $70.00 Subsequent visits are 20 minutes with Dr. Dayal

I also understand that if I miss an appointment or cancel on short notice (less than 24 hours), I may be charged a fee for the missed appointment.

Patient Name Patient Signature

Guardian Signature (If patient is under 16 years old) Date

Doctor’s Signature Doctor’s Name

Welcome! Thank you for taking the time to fill out this extensive questionnaire. Your time and care is appreciated.