INTAKE FORM ADULT. Contact Information. Date

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1 INTAKE FORM ADULT Basic Information Dr Aoife M Earls, BSc, MSc Naturopathic Doctor Suite 212, 345 Lakeshore Rd E, Oakville, ON L6H 6K draoife.com Date Name Date of Birth YYYY-MM-DD Sex F ) M ) Other ) Weight ( lb or kg ) Height ( inches or cm ) Marital Status Single ) Married ) Divorced ) Partnership ) Widowed ) Do you have Children? Y ) N ) If so, list ages / sexes Contact Information Address Phone ( home ) Phone ( work ) City Phone ( mobile ) Province, Postal Code Emergency Contact Name Phone Relationship Health Care Provider Information Family Doctor Phone Other Health Care Provider Phone Health Card Number May we contact your health care providers to update them on your progress? Y ) N ) Where did you hear about Dr Aoife? Internet ) Yellow Pages ) Physician ) Friend ) Other )

2 Health Concerns List your primary health concerns, in order of importance : Medication List all prescription and over-the-counter medications you are currently taking : Supplements List all vitamins, minerals, herbs or other supplements that you take : On Naturopathic Medicine Have you received naturopathic treatment in the past? Y ) N ) What expectations do you have of me as your Naturopathic Doctor? Reversing illness by treating the underlying cause and effectively managing health does not happen overnight. It often requires a commitment to lifestyle change. How would you describe your present level of commitment to making changes in your health on a scale from 1 to 10? ( 0 % ) ( 100 % )

3 Medical History How would you describe your current state of health? Excellent ) Good ) Fair ) Poor ) Please list any serious conditions, illnesses, injuries, surgeries, and/or hospitalizations that you have had in the past Have you had one or more of the following illnesses? Please check all applicable boxes. Scarlet fever ) Diphtheria ) Chicken pox ) Mumps ) Measles ) Mononucleosis ) Rheumatic fever ) Shingles ) Tuberculosis ) Family History RELATION AGE or age at death GENERAL HEALTH ( ie. excellent, poor ) HEALTH CONDITIONS Mother Father Sibling 1 Sibling 2 Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Vaccinations Please list Allergies Do you have any allergies ( environmental, foods, drugs, supplements )? Y ) N ) Please list Have you ever had an anaphylactic reaction ( hives, trouble breathing, etc. )? Y ) N ) Please explain to what ( if known ) and symptoms

4 Lifestyle How often do you eat in a day? What foods do you crave, how often do you eat them? Do you have any food sensitivities? Y ) N ) Please list Do you drink alcohol? Y ) N ) If yes, how often? ( times / day / wk ) Do you smoke cigarettes /cigars / used tobacco? Y ) N ) If yes, how many packs per day? Have you smoked in the past? Y ) N ) If yes, when did you quit? Do you use recreational drugs? Y ) N ) Work & Play What types and how often? What is your occupation? Do you enjoy your work? Y ) N ) When was your last vacation? What do you do for fun? Mental/Emotional Do you exercise? Y ) N ) How often? How would you describe the emotional climate of your home? How stressful is your life and how do you feel you cope with these stressors? Sleep & Energy How many hours do you sleep per night? Bed time : Wake time : Do you fall asleep easily? Y ) N ) If not, how long might it take? ( mins, hr ) Do you wake refreshed? Y ) N ) Do you experience sweating at night? Y ) N ) Do you wake during the night? Y ) N ) What time and how often? Can you fall back to sleep easily? Y ) N ) What time of day is your energy best? Worst? Any unexplained weight loss or gain? Y ) N ) If so, please describe :

5 Review of Systems Please check C if you are currently experiencing the symptom, N if you have never experienced this issue, or P if you have experienced any of the following in the past that was a significant health concern ( you may check both current and past if both are applicable ) Skin Head & Neck Eyes EAR, NOSE & THROAT Eczema C ) N ) P ) Psoriasis C ) N ) P ) Acne C ) N ) P ) Hair loss C ) N ) P ) Itching C ) N ) P ) Dryness C ) N ) P ) Skin colour changes C ) N ) P ) Lumps and / or bumps C ) N ) P ) Hives C ) N ) P ) Change in a mole C ) N ) P ) Headaches C ) N ) P ) Head Injury C ) N ) P ) Migraines C ) N ) P ) Swollen glands C ) N ) P ) Concussion C ) N ) P ) Dizziness ( Vertigo ) C ) N ) P ) Corrective lenses Y ) N ) Double vision C ) N ) P ) Eye pain C ) N ) P ) Spots in vision C ) N ) P ) Tearing or dryness C ) N ) P ) Blurred vision C ) N ) P ) Glaucoma C ) N ) P ) Colour blindness Y ) N ) Itching C ) N ) P ) Cataracts C ) N ) P ) Significant discharge C ) N ) P ) Blind spot C ) N ) P ) Redness C ) N ) P ) Styes C ) N ) P ) Impaired hearing C ) N ) P ) Ringing ( Tinnitus ) C ) N ) P ) Earaches C ) N ) P ) Meniere s disease C ) N ) P ) Discharge C ) N ) P ) Ear infections C ) N ) P ) Sinusitis C ) N ) P ) Nose bleeds C ) N ) P ) Stuffed-up nose C ) N ) P ) Snoring C ) N ) P ) Frequent sore throat C ) N ) P ) Hay fever C ) N ) P ) Teeth grinding C ) N ) P ) Loss of smell C ) N ) P ) Gum problems C ) N ) P ) Loss of taste C ) N ) P ) Amalgam ( mercury ) fillings C ) N ) P ) Sore tongue / mouth C ) N ) P ) Clicking of the jaw C ) N ) P ) Hoarseness C ) N ) P )

6 Lungs CARDIOVASCULAR GASTROINTESTINAL URINARY Cough C ) N ) P ) Pain when breathing C ) N ) P ) Spitting up blood C ) N ) P ) Spitting up mucous C ) N ) P ) Asthma C ) N ) P ) Wheezing C ) N ) P ) Pneumonia C ) N ) P ) Bronchitis C ) N ) P ) Emphysema C ) N ) P ) Daily shortness of breath C ) N ) P ) Tuberculosis C ) N ) P ) Shortness of breath lying down C ) N ) P ) High blood pressure C ) N ) P ) Heart flutter C ) N ) P ) Low blood pressure C ) N ) P ) Fainting C ) N ) P ) Blood clots C ) N ) P ) History of chest pain C ) N ) P ) Varicose veins C ) N ) P ) Mitral valve prolapse C ) N ) P ) History of rheumatic fever C ) N ) P ) Heart attack C ) N ) P ) Swelling in ankles C ) N ) P ) Angina C ) N ) P ) Trouble swallowing C ) N ) P ) Change in thirst C ) N ) P ) Nausea C ) N ) P ) Change in appetite C ) N ) P ) Vomiting C ) N ) P ) Heartburn / Indigestion C ) N ) P ) Vomiting blood C ) N ) P ) Constipation C ) N ) P ) Blood in stool C ) N ) P ) Diarrhea C ) N ) P ) Abdominal pain or cramps C ) N ) P ) Worms / Parasites C ) N ) P ) Belching or passing gas C ) N ) P ) Gall Bladder stones C ) N ) P ) Black, tarry stools C ) N ) P ) Ulcer or H. pylori C ) N ) P ) Jaundice ( i.e. yellow skin ) C ) N ) P ) Hemorrhoids / fissures C ) N ) P ) Liver disease C ) N ) P ) Hernia C ) N ) P ) Bowel movements how often? Change in bowel movements C ) N ) P ) Pain on urination C ) N ) P ) Frequent infections C ) N ) P ) Increased frequency of urination C ) N ) P ) Inability to hold urine C ) N ) P ) Urination at night C ) N ) P ) Kidney stones C ) N ) P ) Urgency or hesitancy C ) N ) P ) Blood in urine C ) N ) P )

7 MALE REPRODUCTIVE SYSTEM Prostatitis C ) N ) P ) Chlamydia C ) N ) P ) Testicular pain or masses C ) N ) P ) Genital warts C ) N ) P ) Impotence C ) N ) P ) Gonorrhea C ) N ) P ) Premature ejaculation C ) N ) P ) Herpes C ) N ) P ) Are you sexually active Y ) N ) Syphilis C ) N ) P ) Do you use contraceptives? Y ) N ) Discharge or sores C ) N ) P ) What type? Female REPRODUCTIVE SYSTEM Age at first menses ( period ) Pain during intercourse C ) N ) P ) Age at last menses ( i.e. Menopause ) Typical duration of bleed ( ie. 5 d ) Typical length of cycle ( ie. 28 d ) Number of pregnancies Number of live births Number of miscarriages MUSCULOSKELETAL Are cycles regular? Y ) N ) Number of abortions PMS C ) N ) P ) Vaginal dryness C ) N ) P ) Painful menses C ) N ) P ) Hot flashes C ) N ) P ) Heavy or excessive flow C ) N ) P ) Chlamydia C ) N ) P ) Bleeding between periods C ) N ) P ) Genital warts C ) N ) P ) Clotting during menses C ) N ) P ) Gonorrhea C ) N ) P ) Unusual vaginal discharge C ) N ) P ) Herpes C ) N ) P ) Vaginal itching C ) N ) P ) Syphilis C ) N ) P ) Date of last PAP YYYY-MM-DD Do you do breast self-exams? Y ) N ) Abnormal PAP C ) N ) P ) Have you had a mammogram? Y ) N ) Endometriosis C ) N ) P ) Breast pain or tenderness C ) N ) P ) Ovarian cysts C ) N ) P ) Breast lumps C ) N ) P ) Cervical dysplasia C ) N ) P ) Nipple discharge C ) N ) P ) Are you sexually active? Y ) N ) Colour ( clear, bloody, other ) Do you use birth control? C ) N ) P ) What methods Joint pain or stiffness C ) N ) P ) Weakness in limbs C ) N ) P ) Broken bones C ) N ) P ) Sciatica C ) N ) P ) Muscle spasms or cramps in legs C ) N ) P ) Backache C ) N ) P ) Joint swelling C ) N ) P ) Neck pain/stiffness C ) N ) P )

8 BLOOD & PERIPHERAL VASCULAR SYSTEMS NEUROLOGICAL ENDOCRINE Easy bleeding / bruising C ) N ) P ) Numbness of hands / feet C ) N ) P ) Deep leg pains C ) N ) P ) Cold hands / feet / other C ) N ) P ) Anemia C ) N ) P ) Swelling in hands / feet C ) N ) P ) Excessive iron C ) N ) P ) Ulcers on hands / feet C ) N ) P ) Seizures C ) N ) P ) Numbness or tingling C ) N ) P ) Muscle weakness C ) N ) P ) Speech difficulties C ) N ) P ) Involuntary body movements C ) N ) P ) Loss of balance C ) N ) P ) Paralysis C ) N ) P ) Nerve damage or irritation C ) N ) P ) MENTAL & EMOTIONAL Excessive thirst C ) N ) P ) Heat or cold intolerance C ) N ) P ) Excessive hunger C ) N ) P ) Low blood sugar C ) N ) P ) Excessive urination C ) N ) P ) Excessive sweating C ) N ) P ) Night sweats C ) N ) P ) Taking hormone therapy? C ) N ) P ) Thyroid issues C ) N ) P ) Temperature changes C ) N ) P ) If so, please describe Treated for emotional issues C ) N ) P ) Memory problems C ) N ) P ) Mood swings C ) N ) P ) Anxiety or nervousness C ) N ) P ) Poor concentration C ) N ) P ) Depression C ) N ) P ) Tension and / or stress C ) N ) P ) Considered / attempted suicide C ) N ) P ) Phobias C ) N ) P ) Seasonal depression C ) N ) P ) Commitment to Self What behaviours or lifestyle habits do you currently engage in regularly that you believe support your health? Which ones are self-destructive to your health? Please list. What potential obstacles do you foresee in adhering to therapeutic protocols? Do you have people who will sincerely and consistently support you with the beneficial lifestyle changes you will be making? Y ) N )

ADULT INTAKE FORM (13 and older) Name Date of First Visit Address City State Zip Code Telephone (home) (work) (cell) Is it ok to leave a message?

ADULT INTAKE FORM (13 and older) Name Date of First Visit Address City State Zip Code Telephone (home) (work) (cell) Is it ok to leave a message? Age Date of Birth Gender Identity Relationship: Single