Patient Intake Pg1 · Gout Anemia Osteoporosis Osteoarthritis High cholesterol Fibromyalgia Chronic...
Transcript of Patient Intake Pg1 · Gout Anemia Osteoporosis Osteoarthritis High cholesterol Fibromyalgia Chronic...
Patient Intake FormBy filling out this comprehensive intake form, you are helping us to provide you with more effective care. We thank you for your time and patience in doing this.
Where did you hear about Living Wellness Centre?
Work TelephoneOccupation
TelephoneName of General Practitioner (MD)
Name of emergency contact
TelephoneRelation to you
May doctor and/or staff contact you at work? Yes No
PATIENT INFORMATION Date
Full Name I go by
Male FemaleBirthday (mm/dd/yy) Age
Care Card Number (PHN)
City Postal Code
Primary Telephone Cellphone
Yes No
Home Address
Office use only MSP Yes No CND Jane W/C GS
Would you like an email reminder for your appointments?
Health History
Are you pregnant?
LIFESTYLE
FOR WOMEN
Type of exerciseHow often do you exercise?
Do you currently smoke?
Overall stress level
Yes No
Yes No Maybe if yes, due date
none low medium high
If yes, by vaginal birth caesarean birthDo you have children? Yes No
Menstrual cycle
Date of your last annual Pap/Breast exam
regular irregular painful cycle
NAME Date
HEALTH ISSUES
Other Concern(s)
Have you ever been treated by any of the following:
Main Concern
Medications
MEDICATIONS
( p r e s c r i p t i o n , over the counter)
Supplements(mult ivi tamins, gingko, etc.)
Please list any medications/supplements you are taking and doses.
Is your condition part of an ICBC or WCB claim? Yes No(If yes, please ask for additional forms.)
Chiropractor NaturopathMassage TherapistAcupuncturist
AdditionalHealth History
SLEEP
DIET
Do you wake well rested in the morning?
Time you go to sleep
Yes No
Time you wake up
Staying asleep?
If yes, please specify:
NAME Date
IMMUNIZATIONS
Check any other vaccines taken:
MEDICATIONS Please check if you use any of the following.
Please list any allergies or sensitivities in the following categories.
Did you receive general childhood vaccinations? Yes No
Hepatitis B OthersFlu shotHepatitis A
Other drugsLaxativesCortisone
Sleeping pills TranquilizersCaffeineAnti-inflammatories
Marijuana Pain relieversAntacidsAlcohol
FAMILY HISTORY Please check if you have a family history of any of the following:
Mental IllnessDrug/alcohol abuseDiabetesStrokeHigh cholesterol Kidney disease
DepressionCancerEpilepsy High blood pressure
Asthma/allergiesArthritis
I don’t know my family history Other
Were you ever on antibiotics for more than 1 month over the last 10 years? Yes No
Have you ever used probiotics (acidophilus) following antibiotic use? Yes No
Do you follow any particular diet regimens or restrictions? Yes No
Do you have problems falling asleep? Yes NoYes No
ALLERGIES
Environmental/chemical
Medications
Foods
Review of systems Please check the appropriate box for any of the following symptoms and add any comments you may feel are important.
Key: P=Past N=Now B=Both
P N B General
Insomnia Fatigue Weight loss Weight gain
Head
Headache Dizziness Head trauma Fainting
Eyes Itching/redness Cataracts Flashes in vision Spots in vision Glaucoma
Mouth and Throat
Bleeding gums Canker sores Colds sores Sore throat Jaw/TMJ problems Hoarseness Goiter
Nose
Hayfever Loss of smell Nosebleeds Sinus problems
Lungs
Asthma Shortness of breath Persistant cough Emphysema Bronchitis
Vascular
Angina Murmurs Chest pain Palpitations Ankle swelling Cold feet/hands Leg cramps Varicose veins Low blood pressure High blood pressure
P N B Gastro-Intestinal
Bloating/gas Heartburn Ulcers Liver disease Gallstones Vomiting/nausea Abdominal pain Diarrhea Constipation Blood in stool Hemorrhoids Hernias
______ # of bowel movements per day Genitourinary
Pain urinating Blood in urine Incontinence Bed-wetting Frequent urination Frequent infections Kidney stones
Neurological
Seizures/epilepsy Strokes Tingling sensation Numbness Muscle weakness Poor coordination Paralysis Speech problems Loss of memory
Muscle & Bone
Joint pain Swollen joints Muscle ache Foot trouble Bone pain Fractures Dislocations
P N B Skin
Rash Itching Hives Change in moles Acne Psoriasis Eczema
Endocrine
Diabetes Hypoglycemia Hormone therapy Thyroid problems Heat/cold
intolerance Excessive thirst Excessive hunger Excessive sweating Night sweats
Emotional
Depression Mood swings Anxiety/nervousness Tension Phobias
Conditions
AIDS/HIV Eating disorders Heart disease Rheumatic fever Cancer/tumor Polio Parkinson’s Multiple sclerosis
Gout
Anemia Osteoporosis Osteoarthritis High cholesterol Fibromyalgia Chronic fatigue Hepatitis
Migraines
TIAs
DIET DIARY Name: ________________________ Start Date:___________
Monday Day ___
Tuesday Day ___
Wednesday Day ___
Thursday Day ___
Friday Day ___
Saturday Day ___
Sunday Day ___
Breakfast
Lunch
Dinner
Snacks
Fluids
BM
Energy
Comments
** BM = Bowel Movements. Please feel free to write on the back of the sheet if more space is required.
Tell Me About Yourself!
I _____________ cooking!
How many times a week do you currently eat the following:
Chicken: Pork: Beef: Turkey: Fish: Other:
What are your top 5 favourite meals/cuisines?
1._____________________________
2._____________________________
3._____________________________
4. _____________________________
5. _____________________________
Do you have any health goals? (e.g. weight loss, increased energy, etc.)
______________________________________________________________________
The Specifics Do you have food allergies?
Yes: No:
If yes, what foods?
______________________________________________________________________
What is the severity of the reaction?
______________________________________________________________________
Do you have dietary restrictions?
Celiac: Gluten Free: Vegan: Vegetarian:
Other:
Do you have food sensitivities or unpleasant reactions to certain foods? (beans, garlic, meat, etc.)
______________________________________________________________________
If yes, to which foods?
______________________________________________________________________
Are there any foods you will not eat?
_____________________________________________________________________
Where do you typically buy your groceries?
______________________________________________________________________
How do you feel about leftovers for lunches?
______________________________________________________________________
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Registered Holistic Nutrition Declaration
& Consent to Treatment
Please read, complete and sign this Client and Consent Agreement. It will explain in detail the services that I, Samantha deSousa, a Registered Holistic Nutritionist, can provide to you. This Agreement will also provide details as to how your personal information will be used for the sole purpose of the services that I provide. I understand the importance of protecting your personal information and will collect only the information needed for a nutritional a/o physical based assessment. CLIENT AGREEMENT I agree to, Samantha deSousa RHN, collecting personal information about me as set out above. I understand and agree that, Samantha deSousa RHN, will keep all documents related to me, included but not limited to any assessment, food diaries, forms, worksheets or any notes that relate to me, as a record of our work together. I understand and agree that, Samantha deSousa RHN, may use any information gathered to document the topics that we discuss about my progress or plans that may be helpful to my health and wellness. Any and all information will be stored in a secure location and any medical records, personal information and health history provided to Samantha deSousa RHN will be kept in strict confidence unless I provide consent to have them released. I may look at and request a copy of my records at any time. I understand and agree that each individual is unique and it will not be possible to determine in advance how my body/system may react to certain foods, drinks or supplements that may be suggested to me. I understand and agree that it may be necessary to adjust my plan from time to time or until such time that my body can properly accept nutritional changes. I understand and agree that it is my responsibility and decision to use or disregard any nutritional and/or lifestyle guidelines.
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I agree to hold Samantha deSousa, RHN harmless for any and all claims or damages in connection with our work together under the terms of this Agreement. I understand and agree that this Agreement is also a release of her liability. I understand and agree that any advice under this program is not a substitute for medical treatment or a varied diet and that all components have been explained to me but I am free to ask any questions that I may have. I understand and agree that after all advice and assistance has been provided to me by Samantha deSousa RHN, that I may withdraw at any time after all fees have been paid in full. Consent Agreement I hereby confirm and agree to the following:
1. I fully understand that Samantha deSousa, RHN, is not a medical doctor and I am not here for medical testing or treatment procedures. If I have any health matters, conditions or disease I have been advised to seek competent medical advice from a licensed practitioner of medicine. I understand and agree that any service provided by an RHN is not designed to cure or prevent any disease, pain, injuries, mental or physical conditions of any kind.
2. I acknowledge that the services performed by Samantha deSousa, RHN is at all times restricted to consultation with respect to nutrition for building wellness and does not involve diagnosing, treatment or prescribing of remedies for the treatment of any disease or for anything that requires a medical license.
3. This agreement is being signed voluntarily and not under the duress of any kind.
4. I have attended this visit, and any subsequent visit(s), solely on my own behalf and not as an agent for any federal, provincial or municipal agency on a mission of any entrapment or investigation.
5. I have read this Consent Agreement, fully understand its terms, understand that I have given up certain rights by signing it and am signing it freely and voluntarily, without any duress or inducement.
6. I understand that completing this form will form part of a legal and binding agreement.
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7. I am aware that 48 hours notice is required for appointment cancellations or a cancellation fee may be applied.
8. I understand that Samantha deSousa, RHN reserves the right to decide which cases are outside of her scope of practice, in which case a referral will be suggested.
I have read this agreement and fully understand its terms. Signature Date Name Registered Holistic Nutritionist Signature