Naturopathy form
Mr.Mrs. First
Last
Ms.Miss. Name:_________________________Name:___________________________________
Home address: ___________________________________Calgary, Postal code: ______________
Home Tel: _____________________ Work Tel: _____________________
Date of Birth: _____________ Age: _______ Occupation: _________________________________
Medical Doctor: ____________________
Referral to clinic: [ ] Yellow pages [ ] Web [ ] Flyer [ ] Adv. [ ] Social club
[ ] Person __________________________
Email Address: ____________________________ [ ] Yes I would like to receive an e-letter
I realize that Naturopathic Medicine is separate and distinct from medical doctors and is not covered under AHC.
Therefore, I take sole responsibility for my consent to follow the advice and treatment suggested by Dr. T. Strasser.
1. I authorize Dr. T. Strasser to perform the following procedure(s) and treatment: - Naturopathy, Homeopathy,
Acupuncture, Neurotherapy, Prolotherapy, Hydrotherapy, Nutritional Counseling, Detoxification, Herbs, Physical
and Lifestyle counseling, IV Therapy or alternate treatment that the doctor considers advisable in the opinion,
judgement and conclusion of the aforementioned doctor.
2. The nature and purpose of the treatment, possible methods of treatment, alternate methods of treatment, the risks
involved and the complications will be fully explained to me by the above named doctor and or their associates
and or assistants.
3. It is my responsibility to comply with therapies for drugs, surgery, chemotherapy, radiation, etc. as prescribed by
the medical profession.
4. I acknowledge that no guarantee or assurance has been made to me as to the results that may be obtained.
5. I understand that when my regular Naturopath is unable to attend me, my care may be administered by an
associate Doctor of Naturopathy, without another consent being prepared.
6. Note: medical records will not be released without your written consent.
7. No refunds on services or packages, NSF cheques subject to bank fees, 24-hour cancellation notice or $25 fee.
I certify that I have read and fully understand the above consent to treatment and that the explanations therein referred
to be in fact made to me and that this form was completed prior to treatment.
Signature of Patient: ____________________________________ Date: _________________ ( DD/MM/YY)
Witness: _____________________________________________ Date: _________________ ( DD/MM/YY)
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Note: when the patient is a minor or otherwise incompetent to give consent, the consent of a parent or guardian must
be obtained.
_________________________________
Signature of Parent or Guardian:
____________________________________
Name of Signatory (Please Print)
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Naturopathy form
Name:__________________________________________________________
Reason for today’s visit: _____________________________________________________________________
List your health goals: _______________________________________________________________________
Any allergies or reactions to drugs or vaccinations? ______________________________________________
Current medication or supplements you are taking: ________________________________________________
________________________________________________________________________________________
Circle any medication you have been on in the past: antibiotics / anti-depressants / anti-inflammatory /
blood thinner / bronchial dilators / cortisone / diuretics / muscle relaxant / pain-killers / sleeping pills / steroids
Do you smoke? Y N In past? Y N How many packs/day? ____
Do you exercise? Y N What form? ____________________________________________________________
Circle if you drink the following daily: coffee / black tea / soda pop / alcohol
Were you breast fed? Y N
Blood type: O / A / B / AB
PERSONAL HISTORY: Check if currently or in the past have you experienced any of the following:
 Allergies
 Cancer
 Hypertension
 Thyroid condition  Prostate problems
 Arthritis
 Depression
 Neurological
 Tuberculosis
 Physical injury
 Asthma
 Diabetes
 Skin disease
 Urinary infection  Headache/migraine
 Alcoholism
 Epilepsy
 Stomach ulcers
 Venereal disease  Constipation
 Blood disorders
 Heart disease
 Stroke
 Viral __________  Chronic Diarrhea
Note any serious illness, trauma, scars or surgery you have had and the year of it: _______________________
__________________________________________________________________________________________
__________________________________________________________________________________________
FAMILY HISTORY: (You may circle the above list)
Father ___________________________________________________________________________________
Mother ___________________________________________________________________________________
Siblings __________________________________________________________________________________
Children __________________________________________________________________________________
WOMEN’S HISTORY:
Premenstrual warning symptoms before your period: (Grade intensity 1=mild 2=moderate 3=severe)
_____ Anxiety
_____ Weight gain
_____ Cravings _____ Depression
____ Oily skin
_____ Irritability
_____ Bloating
_____ Fatigue
_____ Crying
_____ Backache
_____ Mood Swings _____ Breast Tenderness _____ Headache _____ Insomnia
_____ Cramping
Do your premenstrual symptoms get better with your period flow?________________________________
Do you have vaginal discharge or irritation? Y N __________________________________________________
Have you ever had gynecological or breast surgery? Y N____________________________________________
When was your last PAP?_____________ Any abnormal PAP findings?______________________________
Types of Birth Control used:______________________________________________
Could you be pregnant now? Y N _________________________________________
Any pain or discomfort with sexual intercourse? Y N _________________________
Any questions concerning birth control or fertility? Y N _______________________
Times pregnant _____ Living children _____ Miscarriages _____ Abortions _____ Premature Births _____
Complications during your pregnancies: _________________________________________________________
Do you have hot flashes? Y N Are you menopausal? Y N Do you take Hormone replacement? Y N
MEN’S HISTORY:
History of Prostate problems? Y/N
PSA level
Decreased size and force of urinary stream? Y/N
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