February 27, 2013

Consultation form


Please fill in this questionnaire as thoroughly as possible. Things that you might feel are “medically not relevant” can give important information (such as habits, moods, temperament, behavior). Such information might give helpful information about your individual reaction to the illness, and thus help us prescribe the best medication for your problem. Make sure you indicate any recent changes that you have noticed regarding mood, temperament, appetite, sleep patterns, digestion, bowel habits and over all well being.

Upon submission, a licensed physician from our clinic will follow-up with you to finalize the case and to discuss payment options. They will give you guidelines regarding your symptoms, including diet and lifestyle changes. They will make recommendations, if required, for specific diagnostic work and provide you with a prescription for a treatment plan which will be shipped out to you within one business day.


* Indicates Required Fields

    First Name:* Last Name:*
    Age: Sex: MaleFemale
    Address:* City:*
    Province:* E-mail:*
    Postal Code: DOB:
    Phone Home (area):* (Phone): Phone Work (area): (Phone):
    Referral: Occupation:

    Below, describe all of your complaints, how long you have had them and how you are treating them.

    Be sure to mention any drugs, vitamin supplements. or other medicinal substances you are taking.
    Complaint 1: Treatment/Medication
      How long?
    Complaint 2: Treatment/Medication
      How long?

    Complaint 3: Treatment/Medication
      How long?
    Complaint 4: Treatment/Medication
      How long?

    Brief Health History: (list major diseases, surgeries, etc.)

    How many times per year do you get a cold or the flu?

    Diet:(summarize how you eat; list any special diet such as high protein, raw food, etc.)

    Family Medical History:

    Emotions: NormalProblem
    Depression Sadness Panic Attack Sensitive
    Worries Excited Angry Anxiety

    Energy: NormalProblem
      Low Up and Down Exhaust
      Hyperactive Nervous energy Abundant

    Sleep Pattern: NormalInsomnia
    Falling asleep: Sleep Difficult Sometimes very difficult Sleepy in daytime
    Always difficult Always very difficult Take Naps
    Waking up: Times per night Wake up too early
    Wake up at night and cannot go back to sleep again
    Sleep Quality: Deep Light Bad
    Many Dreams Bad Dreams Grinding teeth
    Talking in sleep Other

    Menstrual Cycle: RegularIrregular
    Age of onset:    Date of last period:      (mm/dd/yy)
    Days per cycle: Days it lasts:         
    Color: Pale red  Dark red   Bright red  Purplish
    Do you pass clots? YesNo
    Menstrual Pain: YesNo
    Before Flow During Flow After Flow
    Abdomen Back Breast
    Emotion around period: NormalAbnormal
    Before Flow During Flow After Flow
    Depression Irritability Anger
    Sadness Crying Other

    Temperature: NormalAbnormal
    Feel Cold easily Cold Hands Cold Feet
    Feel Hot easily Alternating Hot
    Hot Flash Sensitive to weather changes

    Perspiration: NormalAbnormal
    Too easily Too much Difficult
    Too little Night sweats Other

    Allergies: YesNo
      Environmental Drug Food

    Appetite and Digestion: RegularIrregular
    Rapid Hungering Poor Appetite Nausea Heartburn
    Indigestion Bloating Gas Other

    Thirst: NormalAbnormal
    Thirsty Dry mouth Dry mouth but no desire to drink
    Drink a lot Not thirsty, but drink a lot of water anyway

    Bowel Movement: NormalAbnormal
    Constipation Diarrhea Loose Watery
    Incomplete Hard and Dry Strong Smell With Mucous
    With Blood Other

    Urination: NormalAbnormal
    Frequent Urgent Burning Painful
    Cloudy Dark color Foul smell Bloody
    Difficult Retention Other
    Number of times per day: Number of times per night:

    Body Weight: NormalOverweightUnderweight
     If overweight:
    How many pounds would you like to lose?
    How many years ago did you first start to gain weight?
    Are you following a weight control program at this time? YesNo

    Please read and click the disclaimer before sending*