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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