229-10610 Southport Rd S.W. Calgary, Alberta T2W 3M6 Tel: (403)689-9889 Fax: (403)668-4257 Welcome to Elite Sport Performance. Your health is influenced by many factors. Sometimes it is hard to determine the true underlying cause of an illness. These patient Intake forms help me to understand the factors which may be contributing to your illness. Please fill out the following questions as thoroughly as possible and bring this from with you to your first visit. General Contact Information
Name: (last, first, middle initial)_________________________________________________________ Date of Birth:_____/_____/______ Age:______ Gender: Male female M D Y Address:____________________________________________________________________________ Town/City:__________________ Province:________________ Postal Code:______________________ Telephone:
Home:________________ Work:_________________ Cell:______________________
May I leave a message on your phone line?
Y
N Preference: Home
/ Work
/ Cell
E-mail:______________________________________________________________________________ How did you hear about our clinic?_________________ Referred by:____________________________ Emergency contact: Name: __________________________________________________________ Relationship: ____________________________________________________ Telephone: ______________________________________________________ Primary Physician: Name: _________________________________ Telephone: _______________ Date of last physical exam: _________________________________________ Other health care providers you are seeing: 1.
2.
3.
tel:
tel:
tel:
Please complete the following questions Please list your health concerns? Please list as many as possible, In order of importance to you. 1. ________________________________________________________________ 2. ________________________________________________________________ 3. ________________________________________________________________ 4. ________________________________________________________________ 5. ________________________________________________________________ Have you tried any previous treatments? What were the results?
Please list any prescription medications, over the counter medications, vitamins or other supplements you are taking, the dosage, and the reason for using them. Medication/supplement
Dosage
Reason for use
1 2 3 4 5 Are you Allergic to any of the following (please List): Drugs?___________________________________________________________________ Foods? ___________________________________________________________________ Environmental allergens? (e.g. Pollen, dust, animal dander, perfume) __________________________________________________________________________ Medical history Please list any serious conditions, illnesses, injuries, or hospitalizations 1. __________________________________________ Date:___________________ 2. __________________________________________ Date:___________________ 3. __________________________________________ Date:___________________ Has there ever been an event or sickness from which you have never fully recovered? No Yes Please explain:____________________________________ Please list any surgeries you have had 1. ____________________ Purpose?_____________________ Date:____________ 2. ____________________ Purpose?_____________________ Date:____________ 3. ____________________ Purpose?_____________________ Date:____________ Environmental Toxic Burden Have you ever been exposed to toxic chemicals, pesticides, herbicides, Radiation, heavy metals (lead, mercury, cadmium, arsenic) at home, work, or while traveling? No Yes please explain______________________________________________________________ Is your home newly built or has it been remodeled recently? Was your home built before 1970? Do you live near a power lines or an incinerary? Do you have Mercury dental fillings? Do you have any surgical implants? (Cosmetic, medical) Do you currently smoke, or do you have a history of smoking? Do you use conventional pesticides on your lawn? Do you use a water filtration system in your home?
No No No No No No No No
Yes Yes Yes Yes Yes Yes Yes Yes
Have you been vaccinated? No Yes Have you experienced reactions to you vaccinations? No Yes If so, Please explain____________________________________________________________________ Family History Pleases indicate whether any family member has/had any of the following: Family member
Family member
Cancer Heart Disease Alcoholism Drug addiction Parkinson’s Alzheimer’s Mental illness
Allergies Asthma Eczema Thyroid conditions Osteoporosis Arthritis Multiple Sclerosis
Other:______________________________________________________________________________ Review of Systems Weight _____lbs
weight 1 year ago____lbs
max weight___lbs
Height______
Please check the box if you are currently experiencing the symptoms, or mark “P” if you have in the past: Mental/emotional Mood swings Poor concentration Depression
Anxiety or nervousness Memory problems Anger
Endocrine Thyroid disease Diabetes Changes in hair growth
Heat or cold intolerance Sugar sensitivities Weight loss/weight gain
Immune Chronic infections Chronic swollen glands Organ transplant
Frequent colds Poor wound healing Severe allergic reactions
Skin Rashes/itching/dryness Acne
Eczema/hives Psoriasis
Head Headaches Dizziness
Migraines Head injury
Ears Earaches Ringing in the ears
Itching of the ears Impaired hearing
Nose and Sinuses Acute sinus congestion Allergies Loss of smell
Chronic sinus congestion Frequent nosebleeds Snoring
Eyes Itchiness or redness of eyes Loss of vision
Dark circles below eyes Pain in, or surrounding eyes
Throat and Mouth Frequent sore throats Inflamed or bleeding gums Burning of tongue/lips
Mucus in throat Metallic taste Loss of taste
Respiratory Cough Difficulty breathing
Coughing up phlegm or blood Shortness of breath
Cardiovascular High/low blood pressure Chest pain while walking Heart pounds easily Swelling of feet and ankles Fatigue easily Coldness of extremities
Chest pain at rest Calf muscle cramp while walking Palpitations Dizziness when standing suddenly Bruise easily Varicose veins
Gastrointestinal Nausea Vomiting Diarrhea Constipation Dependency on laxatives Heartburn Dependency on Antacids Abdominal pain or cramping Excessive Gas Change in appetite How often do you have a bowel movement? ____________________________________________ Urinary Frequent urination Difficulty urinating Incontinence
Frequency at night Pain or burning with urination Chronic infections
Musculoskeletal Painful bones Bone deformities Recent bone fracture Pain in fingers Pain in neck and or shoulders Swollen knees or elbows Stiffness all over
Bone loss Calcium deposits Loss in height Pain in hands/arms Low back pain Muscle cramps Stiffness only in the morning
Neurological Difficulty concentrating Tingling Anxiety Difficulty falling asleep
Loss of memory Loss of sensation Depression Difficulty staying asleep
Women Only Age of your first menstrual period?__________ For how many days do you bleed?__________
Date of your last menstrual period_______ How long is your menstrual cycle?_______
Do you suffer from any of the following premenstrual symptoms? Anxiety Restlessness Food cravings Hypoglycemia Depression/withdrawal Insomnia
Bloating Pain or cramping
Breast tenderness Acne or other skin problems
Are you currently pregnant? Number of pregnancies Number of miscarriages Have you used birth control Have you had a hysterectomy?
Yes No _________ _________ Yes No Yes No
Which type and for how long?
_________
Please indicate if any of the following symptoms apply to you Recurring Yeast infections Difficulty getting pregnant Vaginal discharge Vaginal itching Vaginal odour Abnormal bleeding Pain during intercourse Low libido Abnormal pap test When was your last pap test?
_________
Do you perform monthly self breast exams? When was your last clinical breast exam? Do you have regular mammograms?
Yes No __________ Yes No
Men Only Please indicate if any of the following symptoms apply to you Hernia Testicular mass or pain Discharges Sores Low sex drive Impotence Difficulty conceiving Prostate conditions When was your last prostate exam? _______________________________ Lifestyle Do you exercise? Do you fall asleep easily? Yes No Sleep soundly? Do you smoke tobacco? Do you use drugs? Do you eat out often? Do you drink coffee or tea?
Yes Yes Yes Yes Yes Yes Yes
No No
No No No No No
Vitality Unusual fatigue Decreased libido Decreased self-esteem Do you consider yourself a happy person?
How often?_____________________ Average 6-8 hrs of sleep? Wake rested? Yes No Do you chew tobacco? Yes No Do you drink alcohol? Yes No How often?______________________ Do you drink pop? Yes No
Yes
Excess stress Decreased motivation Decreased satisfaction No
Thank you for taking the time to fill out this questionnaire.
229-10601 Southport Rd S.W. Calgary, Alberta T2W 3M6 Tel: (403)689-9889 Fax: (403)668-4257
CONTACT INFORMATION Full Name: ___________________________________________________________________ Date of Birth: _______________________ Day/Month/Year
Sex: Male
Female
Occupation: ______________________________ Marital Status: _____________ Full Address: __________________________________________________________________ ___________________________________________________________________ Telephone: (home) _______________________
(work) ____________________________
Name of Medical Doctor: ____________________________ Tel: ________________________ Are you currently under his/her care? __________ If 'yes' for what? _______________________ Date of last visit to Medical Doctor: ______________ Date last physical: __________ How did you hear about this clinic? ________________________________________________ Have you been treated by a Naturopathic Doctor before?
Yes
No
If 'yes', by whom? ________________________________ When? _____________________
In Case of Emergency: Contact: _____________________ ______________________ _______________________ Full name Relation Telephone
229-10601 Southport Rd S.W. Calgary, Alberta T2W 3M6 Tel: (403)689-9889 Fax: (403)668-4257
INFORMED CONSENT I would like to take this opportunity to welcome you to Elite Sport Performance. I utilize the principles and practices of Naturopathic Medicine and other complimentary therapies to support the body's innate ability to heal. Through teamwork, we will improve, maintain and optimize your health through natural means. On your first visit, I will conduct a thorough case history. Your second visit will involve a physical exam, thus specific blood and/or urinary laboratory tests may be used as part of your treatment work-up. I emphasize the importance of Patient-Practitioner confidentiality in my office. Should you choose to see another health care practitioner in this facility, it is important to note that there may be some repetition. Should you request that another practitioner have access to your file to minimize the repetition, there is a separate form which will require your written consent. Statement of Acknowledgement Patient’s Name (Please Print)__________________ _______________________________________ As a patient of this clinic I have read the information and understand that the form of medical care is based on Naturopathic and other supportive principles and practices. I also recognize that even the gentlest therapies potentially have their complications in certain physiological conditions or in very young children or those on multiple medications and hence the information provided is complete and inclusive of all health concerns including risk of pregnancy; and all medications, including over the counter drugs and supplements. The slight health risks of some Naturopathic treatments include, but are not limited to: aggravation of pre-existing symptoms, allergic reaction to supplements or herbs; pain, fainting, bruising or injury from venipuncture or acupuncture; muscle strains and sprains, disc injuries from spinal manipulations. I also confirm that I have may choose to accept or reject this care at my own free will. Additionally, I confirm that I am not an agent of any private, local, county, provincial or federal agency attempting to gather information without so stating. I accept full responsibility for any fees incurred during care and treatment.
SIGNATURE:_______________________
Submit by Email
DATE:__________
WITNESS:______________________
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