ADULT INTAKE FORM
480 Fisher St., Suite 100
North Bay, ON P1B 9M9
B: 705.497.8788
F: 705.497.8840
Name: ___________________________________________ Date: ____________________________ Age:______ Gender: M / F
Date of birth: ____________________________________
Email Address: _____________________________________________
Health Card #: _____________________________________ Address: __________________________________________________
Phone (Home): ___________________________________
(Work): ____________________ (Cell): ________________________
Medical Doctor: ___________________________________ Occupation: _______________________________________________
Marital Status: ____________________________________ Height & Weight ___________________________________________
Would you like to receive periodic health newsletters from us?
If so, please check the box.
Emergency Contact:
NAME:______________________________________________________________________
ADDRESS:____________________________________________________________________
PHONE: _____________________________________________________________________
OFFICE USE ONLY:
Who Referred You to this Clinic? ________________________________________________
PRIMARY HEALTH CONCERNS
1. ___________________________________________________________________________________________________________
2. ___________________________________________________________________________________________________________
3. ___________________________________________________________________________________________________________
4. ___________________________________________________________________________________________________________
Others: ______________________________________________________________________________________________________
How did these conditions develop? Are there any specific events (surgeries, drug
reactions, accidents, food, etc.) that you can identify that caused or have
aggravated these conditions? What has improved these conditions?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
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MEDICATIONS:
Prescribed Medications
Dosage
Reason for Use
Supplements: Vitamins, Herbs,
Homeopathics, Minerals
Dosage
Reason for Use
Side Effects
ALLERGIES or SENSITIVITIES
Allergy to:
Past
Current
Explain
Medications
Supplements
Foods
Environment
PAST SURGERIES/ HOSPITALIZATIONS
Surgery/hospitalization
1.
Dates
Hospital/Clinic
Reason
2.
3.
4.
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ILLNESSES / REVIEW OF SYSTEMS
Abscesses
Hay Fever
Prostatitis
Alcoholism
Heart Disease
Rheumatic Fever
Allergies
Hepatitis
Rubella
Amnesia
Herpes Genitalia
Smoker
Angina
Hernia
Sciatica
Arthritis
Hypoglycemia
Sexual Abuse
Asthma
High Blood Pressure
Skin Disease
Bronchitis
Influenza
Strep Throat
Chicken Pox
Kidney Stones
Sinusitis
Cold Sores
Leukemia
Small Pox
Colitis
Malaria
Sunstroke
Depression
Measles
Stroke
Diabetes
Meningitis
Syphilis
Diphtheria
Miscarriage
Tonsillitis
Emphysema
Mononucleosis
Tuberculosis
Epilepsy
Mumps
Typhoid Fever
Frequent Colds
Neuritis or Neuralgia
Thyroid Problems
Gall Stones
Painful/Achy Joints
Venereal Warts
Gastritis
Pancreatitis
Vaccinosis
Goitre
Parasites
Whooping Cough
Gonorrhoea
Pelvic Inflammatory Disease
Worms
Gout
Peritonitis
Warts
Glaucoma
Cancer
Anxiety
Is there any of the preceding conditions after which you have never been totally well again, or which have been more
severe than usual? Y / N
Describe, _______________________________________________________________
What major injuries have you had? When? Have there been any long term effects?
EMOTIONAL:_______________________________________________________________________________________
PHYSICAL:__________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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LIFESTYLE
Is there anything that will get in the way of following a treatment plan in order to achieve results?
__________________________________________________________________________________________________
How many alcoholic drinks do you have:
per day _______________________
per week __________________
Do you have any metal dental fillings? Y / N
Have you had any removed? Y / N
When? ___________________
How many hours of sleep do you get per night? ______________________________
Do you wake often? Y / N
Do you smoke? Y / N
If yes, for how long? _____________ How much? _______________
Do you exercise? Y / N
If yes, how many times per week? ______________________________
FAMILY HEALTH HISTORY
Mother
Father
Siblings
Age
If deceased: age at death
& Cause of death?
Please place a check mark beside the conditions that have occurred among your relatives
Alcoholism
Cancer
Gout
Mental Illness
Allergies
Deafness
High Blood Pressure
Paralysis
Anemia
Depression
Hay Fever
Pneumonia
Arthritis
Diabetes
Heart Disease
Syphilis
Asthma
Eczema
Hyperthyroidism
Stroke
Bleeding Tendency
Epilepsy
Hypothyroidism
Skin Disease
Blindness
Glaucoma
Tuberculosis
Other: __________
Anxiety
Gonorrhoea
Kidney Disease
Other: __________
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Females Only:
Age of First Menses: _________________________
Length of Cycle: _____________________________
Number of Pregnancies: ______________________
Bleeding Between Periods
Y/N
Painful Menses
Y/N
Scanty Flow
Y/N
Difficulty Conceiving
Y/N
Pain During Intercourse
Y/N
Venereal Disease
Y/N
Vaginal Itching
Y/N
Hot Flashes
Y/N
Breast Lumps
Y/N
Nipple Discharge
Y/N
Average Number of Days: ________________________
Last Menstrual Period: ___________________________
Number of Children: ____________________________
Regularity of Cycles
Y/N
Excessive Flow:
Y/N
PMS (mood changes)
Y/N
Are You Sexually Active?
Y/N
Sexual Difficulties
Y/N
Vaginal Discharge
Y/N
Ceasing of Menses
Y/N
Perform Breast Self-Exams?
Y/N
Breast Pain/Tenderness
Y/N
Other: _______________________
Males Only:
Hernias
Testicular Masses
Testicular Pain
Are you Sexually Active?
Sexual Difficulties
Y/N
Y/N
Y/N
Y/N
Y/N
Pain During Intercourse
Y/N
Venereal Disease
Y/N
Discharges
Y/N
Sores
Y/N
Other: ________________________
Thank you for taking the time to fill out this intake form. Full completion ensures better healthcare for you!
I look forward to working with you on your path to wellness.
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