North Bay Naturopathic Clinic

Adult Intake

Name:
Birthday:
Sex:
Address:
Email Address:

Telephone

Home:
Work::
Cell::
May we leave messages relating to your visits?

Emergency contact

Name:
Phone number:
Relation:

Referral

How did you hear about our Clinic:
Referred by:

Other health care providers you are seeing

1.
Phone:
2.
Phone:
3.
Phone:
4.
Phone:
Do you get regular screening tests done by another doctor? (Pap, blood tests, etc.)?
If you are female are you currently pregnant?

Do you have any allergies?

Food
Environmental
Medicine
What are your health concerns, in order of importance to you:
1.
2.
3.
4.

Medical history

How would you describe your general state of health?
Please indicate any serious conditions, illnesses or injuries, and any hospitalizations; along with approximate dates.
ailment 1.
date:
ailment 2.
date:
ailment 3.
date:
ailment 4.
date:

Current/past medications

How many times have you been treated with antibiotics?
Do you frequently use any of the following? AspirinLaxativesAntacidsDiet pillsBirth control pills/implants/injections
Alcohol - how much
Tobacco - form and amount/day
Caffeine - form and amount/day
Recreational drugs - what and how often

Please indicate what immunizations you have had

DPT diphtheria, pertussis, tetanusHaemophilus influenza BHepatitis AFluHepatitis BMMR (measles, mumps, rubella)PolioSmallpox
Tetanus booster; when?
Other
Please indicate if any caused adverse reactions:

Diet

Do you have any food intolerances or dietary restrictions (religious, vegetarian/vegan etc.)?
Intolerances
Restricitons

Family history

Indicate if a close relative (parent, child, sibling) has had any of the following:
Allergies: who
Depression: who
Asthma: who
Mental illness: who
Heart disease: who
Drug abuse: who
High blood pressure: who
Alcoholism: who
Cancer: who
Kidney disease: who
Diabetes: who
Other: who
I don’t know my family medical history YesNo

Environment

Occupation
Hobbies
Do you exercise regularly?
What do you do for exercise, how much, how often?
Are you exposed to significant tobacco smoke (work, home, etc.)?
Are you frequently exposed to animals (work, pets, etc.)?
On a scale of 1 to 5 how would you rate the emotional climate of your home? (1 hostile - 5 peaceful)
On a scale of 1 to 5 how stressful is your work? (1 not at all - 5 very)
On a scale of 1 to 5 how stressful are other aspects of your life? (1 not at all - 5 very)
Rate how well you handle these stresses? (1 not well at all - 5 very)
Is there anything that you feel is important that has not been covered?