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?