Naturopathic Health History Form

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NATUROPATHIC HEALTH HISTORY FORM Name Date In order to ensure safe and optimum care, your naturopathic doctor requires the following information. This information will be kept strictly confidential. PAST MEDICAL HISTORY: Do you suffer from or have you ever been told you have the following conditions and/or diseases? Please check all applicable SKIN: GASTROINTESTINAL: NEUROLOGICAL: Rashes, hives, itchiness Heartburn/acid reflux Fainting/loss of consciousness Moles/warts Trouble swallowing Seizures/convulsions Dry, flaking skin or scalp Changes to appetite/thirst Speech problems/slurring Oily skin Belching/burping Loss of sensation Hair changes (colour/loss) Gas Numbness/tingling Oily or dry hair Bad breath/bad taste in mouth Paralysis Eczema/psoriasis Bloating/abdominal pain Twitching Acne Nausea/vomiting Tremors Night sweats Blood or mucous in stool Significant memory loss Skin infections Black tarry stool Vertigo Rectal bleeding/hemorrhoids HEAD/NECK: Diarrhea BLOOD & LYMPHATIC: Head injury Constipation Anemia Issues with Jaw/TMJ Ulcers Easy bruising/bleeding Dizziness or Light-headedness Gallbladder stones/removal Blood transfusions Swollen glands/lymph nodes in neck Hernia Lymph node swelling Thyroid concerns Hemophilia/clotting problems Pain/stiffness in neck PERIPHERAL VASCULAR: Headaches or migraines Cold hands/feet BLOOD TYPE, IF KNOWN: Ankle/leg swelling A EAR, NOSE & THROAT: Varicose/spider veins B Frequent colds Painful veins AB Allergies/hay fever Deep leg pain/cramps O Sinus problems/infection Weakness in limbs Congestion Phlebitis MUSCULOSKELETAL: Nosebleeds Joint pain/stiffness Frequent sore throat ENDOCRINE: Bone fractures Hoarseness Sensitivity to heat/cold Sciatica Sore or dry tongue/mouth Thyroid problems Muscle weakness Gum disease/bleeding Excessive hunger/thirst Muscle spasms/cramps Cold sores Steroid therapy/use Leg cramping History of ear infections Hormone replacement therapy Back pain Hearing loss Excessive urination/sweating Arthritis Osteoporosis Ringing in ears Low blood sugar/hypoglycemia Diabetes WOMEN: RESPIRATORY: Weight gain Pregnancy Chronic cough Weight loss Shortness of breath Irregular periods Bronchitis Premenstrual symptoms URINARY SYSTEM: Asthma Menopausal concerns Pain/burning with urination Emphysema Incontinence OTHER: Urinary tract infections CARDIOVASCULAR: Hepatitis Blood in urine High blood pressure HIV Low blood pressure Urgency/hesitancy Tuberculosis Irregular heart beat/rate Kidney problems/disease Cancer Chest pain or angina Kidney stones/infection Injuries or hospitalizations Heart disease History of heart attack Pacemaker Stroke/CVA NATUROPATHIC HEALTH HISTORY FORM Previous Surgeries Yes No Current Medications Yes No Date Name Type For what condition Previous Injuries Yes No Current Supplements Yes No Date Name Type For what condition Have you had any of the following tests done recently or previously? X-ray Bone scan Colonoscopy CT scan Blood work Pap smear MRI Urinalysis Breast exam/mammography EMG Fecal occult blood test Please state when and where TD South Tower, 36th Fl., 79 Wellington St. W., Toronto, ON M5K 1J5 | 416-865-0903 | [email protected] | sportmedicineclinic.com.

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Health History
Health History Patient Name ___________________________________________ Date of Birth _______________ Reason for visit ____________________________________________________________________________________________ Past Medical History Have you ever had the following? (Mark all that apply) ☐ Alcoholism ☐ Cancer ☐ Endocarditis ☐ MRSA/VRE ☐ Allergies ☐ Cardiac Arrest ☐ Gallbladder disease ☐ Myocardial infarction ☐ Anemia ☐ Cardiac dysrhythmias ☐ GERD ☐ Osteoarthritis ☐ Angina ☐ Cardiac valvular disease ☐ Hemoglobinopathy ☐ Osteoporosis ☐ Anxiety ☐ Cerebrovascular accident ☐ Hepatitis C ☐ Peptic ulcer disease ☐ Arthritis ☐ COPD ☐ HIV/AIDS ☐ Psychosis ☐ Asthma ☐ Coronary artery disease ☐ Hyperlipidemia ☐ Pulmonary fibrosis ☐ Atrial fibrillation ☐ Crohn’s disease ☐ Hypertension ☐ Radiation ☐ Benign prostatic hypertrophy ☐ Dementia ☐ Inflammatory bowel disease ☐ Renal disease ☐ Bleeding disorder ☐ Depression ☐ Liver disease ☐ Seizure disorder ☐ Blood clots ☐ Diabetes ☐ Malignant hyperthermia ☐ Sleep apnea ☐ Blood transfusion ☐ DVT ☐ Migraine headaches ☐ Thyroid disease Previous Hospitalizations/Surgeries/Serious Illnesses Have you ever had the following? (Mark all that apply and specify dates) Date Date Date Date ☐ AICD Insertion ☐ Cyst/lipoma removal ☐ Pacemaker ☐ Mastectomy ☐ Angioplasty ☐ ESWL ☐ Pilonidal cyst removal ☐ Myomectomy ☐ Angio w/ stent ☐ Gender reassignment ☐ Small bowel resection ☐ Penile implant ☐ Appendectomy ☐ Hemorrhoidectomy ☐ Thyroidectomy ☐ Prostate biopsy ☐ Arthroscopy knee ☐ Hernia surgery ☐ TIF ☐ TAH/BSO ☐ Bariatric surgery
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Nutrition Intake History
NUTRITION INTAKE HISTORY Date Patient Information Patient Address Apt. Age Sex: M F City State Zip Home # Work # Ext. Birthdate Cell Phone # Patient SS# E-Mail Single Married Separated Divorced Widowed Best time and place to reach you IN CASE OF EMERGENCY, CONTACT Name Relationship Home Phone Work Phone Ext. Whom may we thank for referring you? Work Information Occupation Phone Ext. Company Address Spouse Information Name SS# Birthdate Occupation Employer I verify that all information within these pages is true and accurate. _____________________________________ _________________________________________ _____________________ Patient's Signature Patient's Name - Please print Date Health History Height Weight Number of Children Are you recovering from a cold or flu? Are you pregnant? Reason for office visit: Date started: Date of last physical exam Practitioner name & contact Laboratory procedures performed (e.g., stool analysis, blood and urine chemistries, hair analysis, saliva, bone density): Outcome What types of therapy have you tried for this problem(s)? Diet modification Medical Vitamins/minerals Herbs Homeopathy Chiropractic Acupunture Conventional drugs Physical therapy Other List current health problems for which you are being treated: Current medications (prescription and/or over-the-counter): Major hospitalizations, surgeries, injuries. Please list all procedures, complications (if any) and dates: Year Surgery, illness, injury Outcome Circle the level of stress you are experiencing on a scale of 1 to 10 (1 being the lowest):
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Eating Disorders
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GI EFFECTS -Comprehensive
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