Confidential Adult Intake Questionnaire
Successful health care and preventive medicine are possible when the physician has a complete understanding of the patient physically, mentally
and emotionally. Please complete this questionnaire thoroughly and with care as this will help me determine the most effective treatment plan
for you. If you have any questions, note them with a question mark. Thank you!
Name: _________________________________ _______________________________ ____________________________________
(First)
(Last)
Date of Birth: ________________ ______________ _____________
(Month)
(Day)
Age: ___________
(Alternate/Preferred Name)
Gender: _________________________
(Year)
Phone: _____________________________________ E-mail: _________________________________________________________
Address: ___________________________________________________________________________________________________
City: __________________________________________________ Province: _________________ Postal Code: ______________
Occupation: __________________________________________________________________ Hours per week: _________________
Relationship Status: _______________________________________ Spouse’s Name: ____________________________________
Emergency Contact Name: __________________________ Phone: _______________________ Relationship: ______________
Are you in the care of another medical professional? Yes ☐ No ☐
Doctor/Clinic Name: ___________________________________________________ Contact: _____________________________
Do you have any known allergies or emergency information we should know about? Yes ☐ No ☐
If yes, please list: _______________________________________________________________________________________________
_______________________________________________________________________________________________________________
How did you hear about Lonsdale Naturopathic Clinic? ______________________________________________________________
Past Medical History
Please briefly indicate the occurrence of the following (with dates):
Hospitalizations/Surgeries: _____________________________________________________________________________________
Accidents: ____________________________________________________________________________________________________
Previously Diagnosed Conditions: ________________________________________________________________________________
______________________________________________________________________________________________________________
Traumatic Events: _____________________________________________________________________________________________
Toxic Exposures: ______________________________________________________________________________________________
Any other significant history from your past/childhood/birth: _________________________________________________________
_______________________________________________________________________________________________________________
Family History
Please briefly list health history of family members, including heritable conditions such as cancer, diabetes, auto-immune disease,
heart conditions, mental illness, arthritis, asthma etc.
Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Siblings
Other
Age if Alive
Age at Death
Conditions
#404 – 1200 Lonsdale Avenue | North Vancouver, BC V7M 3H6 | P: 604-987-1418 | F: 604-960-9648
Dr. Amy Rolfsen, ND | amyrolfsen.com
Current Health
Please list your most important health concerns in order of importance:
1. ___________________________________________________ 4. ___________________________________________________
2. ___________________________________________________ 5. ___________________________________________________
3. ___________________________________________________ 6. ___________________________________________________
What are your current health goals?
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Please list any medications you are presently taking (please include both prescription and over-the-counter medications):
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Please list any supplements you are presently taking:
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Height: _______________ Weight: _______________ Max/Min Weight: _______________
Do you smoke? Yes ☐ No ☐ If yes, years/amount: _____________________________ Years stopped: ______________
Caffeine (coffee/tea/cola): Yes
☐ No ☐ _______ cups/day
Alcohol: Yes ☐ No ☐ __________ drinks/week
How much water do you drink each day? __________________________________________________________________________
Do you consume a balanced and nutrient-rich diet? Yes ☐ No ☐
List any foods you limit/restrict from your diet: _____________________________________________________________________
Current Stress Levels:
☐Low ☐Moderate ☐High ☐Severe
What are your major sources of stress? _____________________________________________________________________________
Hours of sleep per night? _________ Time to bed: __________ Time awake: __________ Waking at night (#): __________
How often do you have a bowel movement? _______________ Do you frequently have constipation/diarrhea? Yes ☐ No ☐
How is your energy? ☐Extremely Low ☐Barely Enough
☐Good ☐Excellent ☐Too High
Please describe the type, duration and frequency of exercise that you typically do in one week:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Have you travelled recently? Yes ☐ No ☐ Where? ______________________________________________________________
What behaviours do you engage in regularly that you believe are supportive to your health goals?
_____________________________________________________________________________________________________________
What behaviours do you engage in regularly that you believe are counterproductive to your health goals?
_____________________________________________________________________________________________________________
What potential obstacles do you foresee on the way to your health goals?
_____________________________________________________________________________________________________________
What do you LOVE to do?
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
#404 – 1200 Lonsdale Avenue | North Vancouver, BC V7M 3H6 | P: 604-987-1418 | F: 604-960-9648
Dr. Amy Rolfsen, ND | amyrolfsen.com
Overview of Body Systems
Please check any boxes that are current or recurrent concerns
General
 Weight change
 Poor sleep
 Headaches
 Chills/fevers
 Sweat easily
 Cravings
 Sudden energy drop
 Lightheadedness
 Dizziness/fainting
 Bleed/Bruise Easily
Immune System
 Frequent illness
 Never get sick
 Chronic congestion
 Reaction to vaccination
 Past antibiotic use
 Swollen glands
 Auto-immune condition
Eyes, Ears, Nose, Throat
 Dizziness
 Hearing loss/impairment
 Visual loss/impairment
 Loss of smell
 Ear aches/infections
 Ringing in ears
 Sinus infections
 Post-nasal drip
 Sore throats
 Cataracts
 Night or colour blindness
 Nosebleeds
 Eye strain/blurry vision
 Mercury fillings
 Sores/lumps in mouth
 Chronic bad breath
 Tooth problems
 Too much/little saliva/tears
 Sore lips/tongue
Respiratory
 Difficulty breathing
 Chronic cough
 Coughing Blood
 Sputum/phlegm
 Pneumonia/bronchitis
 Asthma
 Allergies (pollen, pets)
Cardiovascular
 High/low blood pressure
 Irregular heartbeat
 Blood clots
 Chest pain
 Anemia
 Cold hands/feet
 Swelling of limbs
 Murmurs
 Varicose veins/hemorrhoids
Skin and Hair
 Rashes/itching/hives
 Acne
 Hair loss
 Weak/brittle nails
 Irregular moles
 Eczema/Psoriasis
Musculoskeletal
 Muscle pain
 Joint pain
 Bone pain
 Muscle spasm/cramps
 Broken bones
 Jaw pain/clicks
Gastrointestinal
 Nausea
 Vomiting
 Loss of appetite
 Abdominal pain
 Heartburn/reflux
 Belching
 Gas
 Gallbladder concerns
 Slow digestion
 Liver concerns
 Poor nutrient absorption
 Laxative use
 Antacid use
 Blood in stool
 Undigested food in stool
 Diarrhea
 Constipation
 Rectal pain
 Itching/burning anus
Genito-urinary
 Pain on urination
 Frequent/urgent urination
 Urinary incontinence
 Kidney stones
 Decrease in urine flow
 Waking to urinate
 Recurrent urinary infection
 Sores on genitals
 Sexually transmitted
infection
 Blood in urine
 Colour/odor? __________
Neurological
 Poor memory
 Balance/coordination
problems
 Numbness/weakness
 Seizures
 Tremors
 Concussion/head injury
 Facial pain/tics
Emotional
 Chronic anger/frustration
 Unresolved grief
 Irritability/quick temper
 Very susceptible to stress
 Mood swings
 Anxiety
 Depression
 Alcohol/Drug abuse
 Emotional eating
 Insomnia
 Nightmares
 Treated for mental illness
 Considered/attempted
suicide
 Irregular cycle
 Bleeding between periods
 Painful periods/cramps
 PMS
 Excessive/light flow
 Missed Periods
 Clots
Age of first period: ______
# of days in cycle: ____
# of days menstruating: ____
Female - Menopause
 Hot flashes
 Night sweats
 Vaginal dryness/itching
 Weight gain
 Low energy
 Low mood
Female – Gynecologic
 Breast tenderness
 Breast lumps/discharge
 Pain during intercourse
 Vaginal discharge
 Vaginal itching
 Recurrent yeast infections
 Sexual difficulties
 Pelvic surgery
 Oral birth control use
 History of abnormal PAP
 Ovarian cysts
 Breast self exam
 Low libido
Date of last PAP: __________
# of pregnancies: ___________
# of live births: ____________
# of miscarriages: __________
# of abortions: _______
Male
 Hernias
 Testicular pain/mass
 Impotence
 Prostate problems
 Discharge/sores
 Sexual difficulties
 Low libido
Female - Menstrual Cycle
#404 – 1200 Lonsdale Avenue | North Vancouver, BC V7M 3H6 | P: 604-987-1418 | F: 604-960-9648
Dr. Amy Rolfsen, ND | amyrolfsen.com
Consent Form
Dear patient:
Naturopathic examination includes: physical and clinical diagnosis, traditional Chinese medical diagnosis and lab work. Therapeutic procedures
include: homeopathy, spinal adjustment, botanical medicine, acupuncture, clinical nutrition, lifestyle counselling, intramuscular injection therapy,
intravenous vitamin/mineral/nutrient therapy and pharmaceutical medications.
Occasionally, complications may arise. Any procedure intended to help may have complications. While the chances of experiencing
complications are minimal, it is the practice of this clinic to inform our patients about them. These complications may include, but are not
limited to: soreness, inflammation, soft tissue injury, dizziness, burns, bruising, stroke, and temporary worsening of symptoms. More serious
complications are extremely rare.
I have read and understand the above statements regarding potential treatment side effects. I also understand that there is no guarantee or
warranty for a specific cure result.
I understand the visit costs for Naturopathic treatment are as follows:
Initial Adult Consultation $150.00
Initial Student/ Senior (65+) Consultation $140.00
The Initial visit is 60 minutes with Dr. Rolfsen
Subsequent Adult Consultation $75.00
Subsequent Student/ Senior Consultation $70.00
Subsequent visits are 30 minutes with Dr. Rolfsen
Subsequent Brief Consultation $40.00
Subsequent Brief Student/ Senior Consultation $35.00
Subsequent brief visits are 15 minutes with Dr. Rolfsen
I also understand that if I miss an appointment or cancel on short notice (less than 24 hours), I may be charged a fee for the missed
appointment.
Signature x____________________________________________ Date x_________
Doctor’s Signature x____________________________________ Date x_________
PARENTAL CONSENT (if applicable)
If you are under the age of 19 parent consent is required for naturopathic treatment.
Signature of Parent/Guardian x____________________________ Date x_________
Welcome!
Thank you for taking the time to fill out this extensive questionnaire. Your answers will help us decipher what is going on so we can
come up with the steps that will lead you to vibrant health!