new patient intake form - new freedom chiropractic · c p ringing in the ears c p jaw / tmj...

7-2016 Tenth Line Rd.Orléans, ON K4A 4X4

(613) 837-9777www.findfreedom.ca

New Patient Intake Form

Patient Contact Information: Today’s Date:______________________________

Name:_____________________________________

Date of Birth:________________________________Age:__________________Gender:_________________

Health Card #____________________________________________________________

Home Address:____________________________________________________________________________

City:__________________________________________________ Postal Code:________________________

Home Phone #:__________________Work#:______________________Cell#:_________________________

Email:__________________________________________________________________

Can we email you invoices, treatment plans and appointment reminders? Yes No

Preferred method for contact:______________________________

Additional Patient Information:

Occupation:_______________________________Employer:____________________hrs/wk:______________

Marital Status (circle): Single Married Divorced With Partner Widow(er)

Person to call in case of an emergency: _____________________Relationship to you:____________________

Phone number contact for them:________________________________

Name of Family doctor:_______________________________________

Other Physicians you see and their specialties:____________________________________________________

How did you first hear about me?:______________________________________________________________

How did you find my contact information:_______________________________________________________

___________________________ _____________________________ ____________________Patient’s Signature Parent/Guardian’s Signature Date

Chief Health Concerns:List your health concerns in order of importance:1.______________________________________________________________________2.______________________________________________________________________3.______________________________________________________________________4.______________________________________________________________________5.______________________________________________________________________

Past Medical History: Please list diagnosis and treatments you have received: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please list all medications you are presently taking with doses and the date you started taking them: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please list any supplements and herbal medicines you are currently taking (include brands and dosages if known): __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

List all surgeries and hospitalizations including the date occurred:1.___________________________________________ 3.________________________________________2.___________________________________________ 4.________________________________________

Please note when and why you had each of the following:X-rays:________________________________ Accidents:________________________________________MRI/Cat scans:_________________________ Last Eye Exam:____________________________________Ultrasounds:___________________________ Last Dental Visit:__________________________________

Please list all sensitivities/allergies/reactions:Drugs: ______________________________________________________________________________________Foods: ______________________________________________________________________________________Environment: ________________________________________________________________________________

General Health HistoryHeight: _____________________ Weight: ________________ Weight one year ago: ________________Level of stress 1-10:___________ Main causes? ________________________________________________________________________________________________________________________________________________Main interests and hobbies: ____________________________________________________________________Exercise Y/N If so, what kind and how often: __________________________________________________________________________________________________________________________________________________Describe your spirituality: __________________________________________________________________________________________________________________________________________________________________

Dr. Rachel Bell, ND 2016 Tenth Line, Unit 7, Orléans, ON K4A 4X4 (613) 837-9777 [email protected]

Do you restrict any foods from your diet? If so, what foods and why?_____________________________________________________________________________________________________________________________Do you drink coffee Y/N How many cups?_______ Black tea Y/N How many cups?______Do you smoke? Y/N How many cigarettes/day?_______ When did you start smoking?______Do you drink alcohol? Y/N How often and how much?___________________________

Choose Yes, No or Past regarding the use of the following:Antacids Y N P Steroids Y N PAnalgesics Y N P Laxatives Y N P Recreational drugs Y N P Addiction Treatment Y N P

Please circle positive or negative and when you had any of the following:TB Test: Positive / Negative ________________________________________HIV Test: Positive / Negative ________________________________________Hepatitis C: Positive / Negative ______________________________________

Family HistoryPlease list health history of family members including conditions such as cancer (including type), diabetes, celiac, stroke, mental illness, arthritis, asthma, learning disability, allergies, eczema etc. Family Member Age if Alive Age at Death ConditionMotherMaternal GrandmotherMaternal GrandfatherFatherPaternal GrandmotherPaternal GrandfatherSiblings

Review of SymptomsPlease mark any of the symptoms you are currently having with a C, or have had in the past with a P


Mental / EmotionalC P Treated for Emotional IssuesC P Mood SwingsC P Considered/Attempted SuicideC P DepressionC P Anxiety/NervousnessC P Difficulty ConcentratingC P Seasonal Depression

EndocrineC P HypothyroidC P Hypoglycemia C P Excessive ThirstC P FatigueC P Heat or Cold IntoleranceC P DiabetesC P Excessive Hunger

SkinC P RashesC P AcneC P Colour ChangeC P LumpsC P EczemaC P ItchingC P Perpetual Hair LossC P Night Sweats C P Hives

HeadC P HeadachesC P MigrainesC P Head InjuryC P Jaw / TMJ Problems

NeckC P GoiterC P Swollen GlandsC P Pain or Stiffness

EarsC P Impaired HearingC P Earaches/Impaired BalanceC P Ringing in the EarsC P Jaw / TMJ problems

Nose & SinusesC P Frequent ColdsC P Sinus ProblemsC P Nose BleedsC P HayfeverC P Loss of Smell


NeurologicC P Seizures or TremorsC P Muscle WeaknessC P Vertigo or DizzinessC P Numbness/TinglingC P Difficulty SleepingC P Loss of Memory

Mouth & ThroatC P Frequent Sore ThroatC P Teeth GrindingC P Gum ProblemsC P Dental CavitiesC P Excessive or Deficient SalivaC P Sore Tongue/LipsC P HoarsenessC P Jaw Clicks

RespiratoryC P CoughC P Spitting up BloodC P AsthmaC P PneumoniaC P EmphysemaC P Pain on BreathingC P Difficulty BreathingC P Shortness of BreathC P SputumC P WheezingC P BronchitisC P Pleurisy

GastrointestinalC P HemorrhoidsC P ConstipationC P DiarrheaC P Blood with StoolC P Abdominal Pain or CrampsC P Gallbladder DiseaseC P Black StoolsC P Colon PolypsC P JaundiceC P Liver Disease

EyesC P Spots in EyesC P Impaired VisionC P Colour BlindnessC P CataractsC P Glasses or ContactsC P Eye Strain/PainC P Tearing or Dryness

UrinaryC P Pain on UrinationC P Increased FrequencyC P Frequent InfectionsC P Frequency at NightC P Inability to Hold UrineC P Kidney Stones

CardiovascularC P Chest PainC P High CholesterolC P Heart DiseaseC P High/Low Blood PressureC P Blood ClotsC P PhlebitisC P Rheumatic FeverC P Swelling in AnklesC P AnginaC P Palpitations/Fluttering

MusculoskeletalC P Joint Pain or StiffnessC P Broken BonesC P Muscle Spasms or CrampsC P ArthritisC P WeaknessC P Sciatica

BloodC P Easy Bleeding or BruisingC P Deep Leg PainC P Varicose VeinsC P AnemiaC P Cold Hands/FeetC P Thrombophlebitis

ImmuneC P Reaction to VaccineC P Chronic Swollen GlandsC P Chronic/Recurrent InfectionsC P Slow Wound Healing

Female ReproductiveC P PMSC P Abnormal PAPC P MiscarriageC P AbortionC P Difficulty ConceivingC P Nipple Discharge C P Breast LumpsC P Sexually Transmitted Disease

Male ReproductionC P Premature EjaculationC P Testicular MassesC P Discharges or SoresC P Sexually Transmitted DiseaseC P Impotence

Review of SymptomsPlease mark any of the symptoms you are currently having with a C, or have had in the past with a P



CONSENT TO TREAT

Naturopathic medicine is the treatment and prevention of diseases by natural means. Naturopaths assess the whole person, taking into consideration physical, mental, emotional and spiritual aspects of the individual. Gentle, non-invasive techniques are generally used in order to stimulate the body’s inherent healing capacity.

At your first appointment you can expect a thorough medical history and physical examination. Any relevant lab work that is necessary will be ordered or referred for at this time. Because some therapies must be used with caution when dealing with particular conditions (such as pregnancy and lactation, kidney disease, and heart disease), it is very important that you inform your naturopathic doctor imme-diately of any disease that you are suffering from, as well as any forms of medication, drugs, or supple-ments you are taking.

There are some slight health risks to treatment by naturopathic medicine. These include but are not limited to: • Aggravation of pre-existing symptoms • Allergic reactions to supplements or herbs • Pain, bruising or injury from venipuncture or acupuncture • Fainting or puncturing of an organ with acupuncture needles

I understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others unless so directed by myself unless law requires it. I understand that I may look at my medical record at anytime and can request a copy of it by paying the appropriate fee.

I understand that the results are not guaranteed. I do not expect the Naturopathic Doctor to be able to anticipate and explain all risks and complications.

I intend this consent form to cover the entire course of treatment for my present condition. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time.

Patient Name: (Please Print) ___________________________________________

Signature of Patient (or Guardian): ____________________________________

Date: ___________________________________________

Naturopathic Doctor: _____________________________________________ Dr Rachel Bell, ND. #2943




PRIVACY POLICY FORM

Privacy of your personal information is an important part of your experience with Rachel Bell, Naturopathic Doctor (ND). I understand the importance of protecting your personal information while providing you with high quality naturopathic care. I am committed to collecting, using and disclosing your personal information responsibly.

To demonstrate this commitment to you, please find below an outline of how the office is using and disclosing your information: • Only necessary information is collected about you • I only share your information with your consent • Storage, retention and destruction of your personal information complies with existing legislation and privacy protection protocols. • My privacy protocols comply with privacy legislation and standards of our regulatory body, the College of Naturopaths of Ontario.

HOW MY CLINIC USES, COLLECTS AND DISCLOSES PERSONAL INFORMATION • To assess your health concerns • To provide health care • To advise you of treatment options • To establish and maintain contact with you • To send you newsletters and other information mailings • To remind you of upcoming appointments • To communicate with other treating health-care providers • To allow us to efficiently follow-up for treatment, care and billing • To complete claims for insurance purposes • To invoice for goods and services • To process credit card payments • To collect unpaid accounts • To comply with all regulatory and legal requirements including court orders, statutory requirements to advise authorities of child abuse, reportable diseases and individuals who may be an imminent threat to harm themselves or others

By signing this patient consent form you have given your consent to collection, use and/or disclosure of your personal information as outlined above.

I have reviewed the above information that explains how Rachel Bell, ND will use my personal information and the steps that she is taking to protect my information. I agree that Rachel Bell, ND can collect, use and disclose personal information about me or my child as set out in the above privacy policy.

____________________________________ ______________________________ _____________________Signature Print Name Date


new patient intake form - new freedom chiropractic · c p ringing in the ears c p jaw / tmj...

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