NATUROPATHY INTAKE FORM - Physiomobility · Dr. Vivian Bizios ND 6 Maginn Mews, Suite 211 Toronto,...
Transcript of NATUROPATHY INTAKE FORM - Physiomobility · Dr. Vivian Bizios ND 6 Maginn Mews, Suite 211 Toronto,...
Dr. Vivian Bizios ND
6 Maginn Mews, Suite 211 Toronto, ON M3C 0G9
Phone: 416-444-4800 | Fax: 416-444-4811
www.physiomobility.com | [email protected]
NATUROPATHY INTAKE FORM
Date: _______________
Last Name: ________________________ First Name: __________________________
Date of Birth (yyyy/mm/dd): _________________ Age: _________________
Marital status: ___________________________
Address: ____________________________________ City: ___________________________
Province: ___________________________________ Postal Code: _____________________
Phone (Home): __________________________________ Cell #: ____________________________
Phone (Work): ___________________________________
Occupation: _________________________________________________________________
Employer: ___________________________________________________________________
Name of Medical Doctor: ____________________________ Phone #: _________________
Who can we thank for referring you to us? _________________________________________
Please list your major complaints in order of importance:
COMPLAINT(S) FOR HOW LONG?
1. ___________________________________________ ___________________________
2. ___________________________________________ ___________________________
3. ___________________________________________ ___________________________
4. ___________________________________________ ___________________________
MEDICATION(S)/SUPPLEMENT(S) FOR HOW LONG?
1. ___________________________________________ ___________________________
2. ___________________________________________ ___________________________
3. ___________________________________________ ___________________________
4. ___________________________________________ ___________________________
Immunizations and reactions, if any? _____________________________________________
Operations or significant injuries, if any? ______________________________________________
FAMILY MEDICAL HISTORY
Mother: _______________________________ Father: _______________________________
Grandparents: __________________________ Siblings: _____________________________
Children: ______________________________
Dr. Vivian Bizios ND
6 Maginn Mews, Suite 211 Toronto, ON M3C 0G9
Phone: 416-444-4800 | Fax: 416-444-4811
www.physiomobility.com | [email protected]
LIFESTYLE
Please check if you use any of the following:
☐ Alcohol ☐ Eating out times per week ☐ Bottled water
☐ Recreational drugs ☐ Plastic Tupperware for storage ☐ Fast Food
☐ Smoking/vaping ☐ Tap water ☐ Fried Food
☐ Candy/refined sugar ☐ Filtered water ☐ Carbonated beverages
☐ Cold cuts ☐ Coffee, # of cups? __________ ☐ Aluminum pans, Teflon
LIFESTYLE
Exercise? ☐ Yes ☐ No What type? ________________ How Often? __________
How many hours of sleep a night? _________ Do you sleep well? ☐ Yes ☐ No
Awaken rested? ☐ Yes ☐ No
Excessive stress in life? ☐ Yes ☐ No Eat 3 meals a day? ☐ Yes ☐ No
Enjoy work? ☐ Yes ☐ No Wifi/cell phones on during sleep? ☐ Yes ☐ No
Mold in home? ☐ Yes ☐ No Radon tested home? ☐ Yes ☐ No
Use natural cleaning products? ☐ Yes ☐ No Asbestos in home? ☐ Yes ☐ No
Living close to hydro tower/cell tower? ☐ Yes ☐ No
Pesticide use of property? ☐ Yes ☐ No
Please check any condition you have now or have had in the past:
A. General Symptoms Depression Lumps Vertigo
Wt._____ Ht._____ Anxiety Colour Changes Ear Infections
Fatigue & Weakness Alcoholism Mole Changes Discharge from Ear
Fever Cancer C. Head E. Eyes
Chills B. Skin Headache Impaired Vision
Sweats Rashes Dizziness Glaucoma
Loss of Weight Eczema Head Injury Cataracts
Weight Gain Psoriasis Migraines Double Vision
Anemia Acne D. Ears Bothered by Sun
Blood Transfusions Itchy Impaired Hearing Eye Pain
Easy Bruising & Bleeding Dryness Ear Pain Eye Itching
Lymph Node Swelling Oily Ringing Eye Redness
Food Allergies Hair Changes Loss of Balance Tearing
Drug Allergies Temperature Changes Dizziness Eye Dryness
Dr. Vivian Bizios ND
6 Maginn Mews, Suite 211 Toronto, ON M3C 0G9
Phone: 416-444-4800 | Fax: 416-444-4811
www.physiomobility.com | [email protected]
Blurring Chest Pain & Angina Increased Frequency Cold Intolerance
Eye Discharge Heart Attack Urgency Thyroid Problems
F. Nose & Sinuses Stroke Hesitancy Diabetes
Nose Bleeds Heart Murmur Inability to Hold Urine Hypoglycemia
Allergies High Blood Pressure Blood in Urine Hormone Therapy
Sinus Problems High Cholesterol Frequent Bladder or Q. Infectious Diseases
Congestion Purplish/Bluish Skin Kidney Infections Chicken Pox
Discharges Palpitations & Fluttering Kidney Disease Shingles
Polyps Ankle Swelling Kidney Stones Measles
G. Mouth & Throat Gout M. Musculoskeletal HPV
Frequent Cold & Flu K. Gastrointestinal Joint Pain & Stiffness HIV
Frequent Sore Throat Trouble Swallowing Joint Swelling Warts
Strep Throat Increase/Decrease Thirst Arthritis Parasite (ever?)
Lost of Taste Increase/Decrease
Appetite Back Pain R. Male
Cold Sores Nausea Bone Density Test
(ever?) Hernia
Sore Tongue & Mouth Vomiting N. Arms, Legs, Hands Testicular Mass
Cankers Heartburn & Indigestion & Feet Testicular Pain
Bleeding Gums Belching & Passing Gas Deep Leg Pain Low Libido
Dental Cavities &
Fillings Number of Bowel Cold Hands & Feet Sexually Active
Implants Movements per Day Varicose Veins Sexual Difficulties
Root Canals Constipation Numbness in Hands & Prostate Problems
Tonsils Removed Diarrhea Feet Tingling Discharge
Mono Blood in Stool Coldness Sores
H. Neck Hemorrhoids/Fissures Swelling Rectal Itching
Lumps Abdominal Pain Ulcers Feet S. Women
Pain or Stiffness Hernias Tingling Duration of Menses (days)
Enlarged Lymph Nodes Ulcer O. Neurologic Length of Cycle (days)
Enlarged Thyroid Liver Disease Fainting Irregular Cycles
I. Respiratory Colonoscopy (ever?) Seizures/Convulsions Painful Menses
Cough Diverticulosis
Epilepsy Bleeding Between
Menses
Wheezing Polyps Loss of Memory Excessive Flow
Asthma Appendix Removal Speech Problems P.M.S.
Bronchitis Gall Stones Involuntary Movement Low Libido
Throat Phlegm Gallbladder Removal Paralysis Sexually Active
Breathing Difficulties L. Urinary P. Endocrine Sexual Difficulties
J Cardiovascular Pain Before & During Heat Intolerance Pain During
Intercourse
Heart Disease Urination Cold Intolerance Birth Control
Dr. Vivian Bizios ND
6 Maginn Mews, Suite 211 Toronto, ON M3C 0G9
Phone: 416-444-4800 | Fax: 416-444-4811
www.physiomobility.com | [email protected]
S. Number of Pregnancies
Breastfeeding
Miscarriages
Abortions
Uterine Fibroids
Uterine Polyps
Ovarian Cysts
Vaginal Discharge
Vaginal Itching
Vaginal Yeast Infections
Genital Herpes
Menopausal Symptoms
Last Breast Exam (Date)
Last Pap Exam (Date)
Patient’s Name: ____________________________________
Patient / Guardian’s Signature: ________________________ Date: _______________