ADULT INTAKE FORM Please complete this form as thoroughly as possible. The information provided is kept strictly confidential.

CONTACT INFORMATION Full Name: ______Date of Birth: ______(DD/MM/YYYY) Sex: Male Female (Please circle) Address and postal code: ______Telephone: (daytime) (_____)______(evening) (_____)______e-mail: ______In Case of Emergency: Contact: ______Tel: (______)______Relation______

How did you hear about this clinic? ______Have you been treated by a Naturopathic Doctor before? Yes / No (Please circle) If yes, by whom? ______When? ______

Name of Medical Doctor: ______Tel: (_____)______Address: ______Fax: (_____)______Date of last visit to Medical Doctor: ______Date last physical:______

Other health care providers (i.e. Medical Doctor, Pediatrician, Chiropractor) you are seeing: Designation Name Address Telephone 1. 2. 3.

Please list your health concerns, in order of importance to you: 1.______2. ______3. ______4. ______

HEALTH HISTORY Please list any major trauma, injury, illness or accident (mental, emotional or physical) you have sustained or surgical procedures. Incident /Procedure Date Long-term effects/results CHILDHOOD ILLNESSES & VACCINATIONS (circle all that apply): Were you vaccinated as a child? YES NO Chicken pox Measles Mumps Rheumatic Fever Roseola Polio Scarlet fever Tuberculosis Whooping Cough Impetigo Ear Infections Strep Throat Mononucleosis Rubella (German measles) Any known side effects?______Any additional vaccinations (i.e. Heapatis A or B, “Flu shot”,etc)?______

MEDICATIONS / SUPPLEMENTS / DRUGS Please list all current prescription medications: Name of Dose Frequency Duration Side effects (if medication any)

Please list all vitamins, herbs, homeopathics, and non-prescription medications that you take on a regular basis: Name Brand Dose Frequency Duration Side effects (if any)

How often did you take antibiotics as a child?______In the last 5 years how many courses of antibiotics have you taken?______Most recent course? ______Which of the following have you used / do your currently use? Please include amount, frequency, duration of use. Tobacco Cortisone

Alcohol Antacids

Recreational Drugs Sedatives

Steroids Laxatives

Other Coffee

Please List any known Food allergies, Drug Sensitivities and/or intolerances (Drugs, food, environment and so on):

______

______

Diet: Please list your most typical breakfast, lunch, dinners and snacks.

Breakfast:

Snack:

Lunch:

Snack:

Dinner:

Snack: Beverages: Please list how many cups a day you have:

Water:

Tea:

Coffee:

Milk:

Pop:

Juice:

Alcohol: SYSTEMS REVIEW: Please check (C) for current and (P) for past. For Other please list. SKIN C P HEAD C P Lumps Tension Headaches Rashes Migraine Headaches Hives Head injury Acne Dizziness Boils Other Eczema Psoriasis NECK Dry Skin Lumps itching Swollen glands Other Goiter Pain or stiffness NOSE AND SINUS Other Frequent Colds Nose Bleeds EARS Stuffiness Impaired hearing Hay Fever Earaches Other: Dizziness Infections CARDIOVASCULAR Excessive Wax Angina Other Murmurs Chest Pain EYE Swelling in Ankles Impaired vision Palpitation, fluttering Use of contact lenses/glasses Last ECG Eye pain Other Tearing Dryness MOUTH AND THROAT Double vision Hoarseness Glaucoma Gum Problems Cataracts Difficulty swallowing Blurring Sores Light sensitivities Dryness Itching Sore throat Redness Loss of taste Discharge Other Blind spot Other RESPIRATORY C P BLOOD/LYMPHATIC C P Cough Anemia Sputum Last chest xray Spitting up Blood Easy bleeding/bruising Wheezing Past transfusion Asthma Lymph node swelling Bronchitis Other Pneumonia Emphysema URINARY Difficulty/Pain on breathing Pain on urination Shortness of breath Increased frequency/frequency at night Positive TB test Inability to hold urine Frequent infections GASTROINTESTINAL Kidney stones Trouble swallowing Blood in urine heartburn Reduced urine flow Change in appetite Other nausea Vomiting Endocrine Vomiting blood Heat/cold intolerance Belching Thyroid trouble Passing gas Excessive thirst Abdominal pain Excessive hunger Indigestion Excessive sweating Diarrhea Diabetes Constipation hypoglycemia Blood in stool Hormone therapy Hemorrhoids Night sweats Black tarry stool Other Jaundice Liver disease PEREPHERAL VASCULAR Gallbladder issues Cold hands/feet Food allergy Varicose veins Hiatus hernia Thrombophlebitis Last colonoscopy Leg cramps Other Extremity numbness/coldness Extremity swelling/ulcers Other NEUROLOGICAL C P FEMALE REPRODUCTIVE CONT. C P Fainting Heterosexual Seizures/Convulsions Homosexual Paralysis Bisexual Muscle weakness menopause Numbness or tingling Age of onset of menopause Loss of memory/Brain fog Hormone therapy Involuntary movement Last gynecological exam Loss of balance Other Speech problems Other MALE REPRODUCTIVE hernia BREASTS Testicular Masses Do you do your own self breast Testicular Pain exam? Lumps Impotence Pain/tenderness Premature ejaculation Nipple discharge Venereal disease Last Mamogram Sexually active Other Heterosexual Homosexual FEMALE REPRODUCTIVE Bisexual Age of first menses Last prostate exam Number of days of menses Last PSA level Length of cycle Other Bleeding between periods Irregular cycles EMOTIONAL Pain during intercourse Depression Painful menses Angry PMS Mood swings Excessive flow Anxiety Number of pregnancies Nervousness Number of live births Tension Number of miscarriages Phobia Number of abortions Insomnia Difficulty conceiving Drug Abuse Sexual difficulties Psychiatric care Vaginal discharges Vaginal itching Sexually Active FAMILY HISTORY Please indicate if any of your immediate family (parents, siblings, maternal & paternal grandparents) suffers from or has suffered from any of the following conditions. If a condition is not listed please list it here : ______

Condition Family Condition Family Condition Family Member(s) Member(s) Member(s)

Alcoholism/ Depression/ Colitis Drug use mental health Allergies / Heart Disease Liver Disease hay fever Asthma Prostate Cancer High Blood Pressure Diabetes Breast Hyper / hypo Cancer thyroidism Arthritis Colon Overweight / Cancer obesity Stroke Other Cancer Kidney Disease

ENVIRONMENT AND LIFESTYLE Occupation: ______Do you exercise regularly? Y N What types: ______How often?______How would you describe the emotional climate of your home? ______

Do you currently face or have you faced any of the following? √ Year √ = Year = yes yes Loss of someone Alcohol/drug close addiction Illness in someone Alcohol/drug close addiction in someone else A move Physical abuse Marriage Emotional abuse Separation Sexual abuse Change of job Pregnancy Change of workplace Divorce Loss of job Other (please specify)