SECTION 1 (New Patient Questionnaire) Thank you for visiting the Upper Canada Naturopathic Clinic on-line. Please fill in the following questionnaire and submit it prior to your first visit. The following form has 14 parts and can be filled out and submitted electronically by clicking the button at the end of each page, or you may fax it to us at 416-709-8565. We require detailed information to make an effective diagnosis, your cooperation is greatly appreciated. Please complete the form as much as possible, if there are sections that you are unsure about, leave them blank. Please note that all information gathered is strictly confidential. For further information on naturopathic medicine please look at the Equilibrium Naturopathic Clinic. Indicates a required field. First Name Last Name Street City Province Ontario British Columbia Postal Code Home Phone Bus. Phone Height Date of Birth Weight(lbs.) (dd) (mm) (yyyy) email Please state your primary reasons for attending this office. If this involves a specific health condition, please describe it in detail. Please list the 5 most significant, stressful events in your life, from the most recent to the most distant. Are any of these situations continuing to impact your life? If so, please indicate these clearly. Have you consulted a medical doctor regarding the aforementioned condition(s)? Please explain his diagnosis, therapy, and the results. Please list all the secondary health conditions which you are aware of whether you feel they are related to the previously reported condition(s) or not. Please list all drugs/medications which you are presently use or have used in the past and why? Please reflect carefully as your current health state may relate directly to the treatment of a past health problem. Do you chew tobacco, smoke cigarettes, cigars, pipe, hashish or marijuana? Please indicate quantity and frequency of use. Do you consume alcohol? What type? Indicate approximate consumption per week. SECTION B -- Health History Please indicate whether there is any history of the following conditions in your family and give details below (please be accurate) Heart Disease, Cancer, Diabetes, Osteoarthitis, Anlkylosing-Spondilitis, Rheumatoid Arthritis, Multiple Sclerosis, Muscular Dystrophy, Mental Illness, Auto-immune disorders, Allergies, Alcoholism, Drug Abuse or any other conditions which might be pertinent to your state of health. Was your mother's health good throughout her pregnancy when carrying you? Was you birth process natural? i.e Without medical intervention, such as Forceps, C-section, Epidural Anesthesia, etc. Were you separated from your mother for any medical reason after birth? For approximately how long and why? Were you breast fed within the first 10 hours after birth? Were you breast fed at all, and for how long? Were you a colicy baby? Until what age? Did you require any medical attention, hospitalization, or medication as a baby? As a child Please explain "Yes" answers. Have you had any surgery? Please list all surgeries, their approximate dates, and why they were performed. Have you had any illness other than the ordinary self-limiting childhood diseases of the measles, mumps and chickenpox? Please explain. Have you ever had worm or parasite infections? Have you ever had scarlet or rheumatic fever? Have you ever been diagnosed as having Cancer, Diabetes, M.S., M.D., Arthritis, A.I.D.'s, Hepatitis, chronic Mono (Epstein Barr) or any heart conditions? Explain Have you ever had any disease conditions involving the bones, muscles, ligament or tendons? Explain. Have you had any re-occurring infections? i.e Tonsillitis, Bladder or Ear Infection, Vaginitis, Colitis, Sinusitis, Yeast Overgrowth, Mastitis, Dental Abcesses, etc.? Please explain fully. Have you had any respiratory disorders? i.e Pneumonia, Bronchitis, Asthma, etc.? Please Explain. How many times each year do you have a Cold, Sinusitis, the Flu, Sore Throat or Bronchitis? How long do they usually last? Have you had any venereal disease or genital herpes? Have you ever fainted, blacked out or had a convulsion? Please Describe. Do you wear a medical alert bracelet or tag? For what condition? Do you have any allergies to foods, drugs or inhalents? How do you react? Please list and describe in detail.
SECTION 1 (New Patient Questionnaire)
Indicates a required field.
First Name Last Name Street City Province Ontario British Columbia Postal Code Home Phone Bus. Phone Height Date of Birth Weight(lbs.) (dd) (mm) (yyyy) email Please state your primary reasons for attending this office. If this involves a specific health condition, please describe it in detail. Please list the 5 most significant, stressful events in your life, from the most recent to the most distant. Are any of these situations continuing to impact your life? If so, please indicate these clearly. Have you consulted a medical doctor regarding the aforementioned condition(s)? Please explain his diagnosis, therapy, and the results. Please list all the secondary health conditions which you are aware of whether you feel they are related to the previously reported condition(s) or not. Please list all drugs/medications which you are presently use or have used in the past and why? Please reflect carefully as your current health state may relate directly to the treatment of a past health problem. Do you chew tobacco, smoke cigarettes, cigars, pipe, hashish or marijuana? Please indicate quantity and frequency of use. Do you consume alcohol? What type? Indicate approximate consumption per week. SECTION B -- Health History Please indicate whether there is any history of the following conditions in your family and give details below (please be accurate) Heart Disease, Cancer, Diabetes, Osteoarthitis, Anlkylosing-Spondilitis, Rheumatoid Arthritis, Multiple Sclerosis, Muscular Dystrophy, Mental Illness, Auto-immune disorders, Allergies, Alcoholism, Drug Abuse or any other conditions which might be pertinent to your state of health. Was your mother's health good throughout her pregnancy when carrying you? Was you birth process natural? i.e Without medical intervention, such as Forceps, C-section, Epidural Anesthesia, etc. Were you separated from your mother for any medical reason after birth? For approximately how long and why? Were you breast fed within the first 10 hours after birth? Were you breast fed at all, and for how long? Were you a colicy baby? Until what age? Did you require any medical attention, hospitalization, or medication as a baby? As a child Please explain "Yes" answers. Have you had any surgery? Please list all surgeries, their approximate dates, and why they were performed. Have you had any illness other than the ordinary self-limiting childhood diseases of the measles, mumps and chickenpox? Please explain. Have you ever had worm or parasite infections? Have you ever had scarlet or rheumatic fever? Have you ever been diagnosed as having Cancer, Diabetes, M.S., M.D., Arthritis, A.I.D.'s, Hepatitis, chronic Mono (Epstein Barr) or any heart conditions? Explain Have you ever had any disease conditions involving the bones, muscles, ligament or tendons? Explain. Have you had any re-occurring infections? i.e Tonsillitis, Bladder or Ear Infection, Vaginitis, Colitis, Sinusitis, Yeast Overgrowth, Mastitis, Dental Abcesses, etc.? Please explain fully. Have you had any respiratory disorders? i.e Pneumonia, Bronchitis, Asthma, etc.? Please Explain. How many times each year do you have a Cold, Sinusitis, the Flu, Sore Throat or Bronchitis? How long do they usually last? Have you had any venereal disease or genital herpes? Have you ever fainted, blacked out or had a convulsion? Please Describe. Do you wear a medical alert bracelet or tag? For what condition? Do you have any allergies to foods, drugs or inhalents? How do you react? Please list and describe in detail.
First Name Last Name Street City Province Ontario British Columbia Postal Code Home Phone Bus. Phone Height Date of Birth Weight(lbs.) (dd) (mm) (yyyy)
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