February 27, 2013 admin

Consultation form

NEW PATIENT INFORMATION INTAKE

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

    Describe:

    Energy:

    NormalProblem

     

    Low

    Up and Down

    Exhaust

     

    Hyperactive

    Nervous energy

    Abundant

    Describe:

    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

    Describe:

    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

    Describe:

    Temperature:

    NormalAbnormal

    Feel Cold easily

    Cold Hands

    Cold Feet

    Feel Hot easily

    Alternating Hot

    Hot Flash

    Sensitive to weather changes

    Describe:

    Perspiration:

    NormalAbnormal

    Too easily

    Too much

    Difficult

    Too little

    Night sweats

    Other

    Describe:

    Allergies:

    YesNo

     

    Environmental

    Drug

    Food

    Describe:

    Appetite and Digestion:

    RegularIrregular

    Rapid Hungering

    Poor Appetite

    Nausea

    Heartburn

    Indigestion

    Bloating

    Gas

    Other

    Describe:

    Thirst:

    NormalAbnormal

    Thirsty

    Dry mouth

    Dry mouth but no desire to drink

    Drink a lot

    Not thirsty, but drink a lot of water anyway

    Describe:

    Bowel Movement:

    NormalAbnormal

    Constipation

    Diarrhea

    Loose

    Watery

    Incomplete

    Hard and Dry

    Strong Smell

    With Mucous

    With Blood

    Other

    Describe:

    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:

    Describe:

    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

    Describe:

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