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Dr. Ashley Kowalski, BSc., Naturopathic Doctor (ND)
1419 Carling Ave. Suite 209, Ottawa, ON, K1Z 7L6
613.761.1600 - info@hamptonwellnesscentre.com
** Please be advised we have a scent-free policy **
New Patient Instructions and Appointments:
Welcome. This form is a little lengthy but it's purpose is to help us get the best use of our time together.
Naturopathic medicine is the treatment and prevention of diseases by natural means. A naturopathic intake
assesses the whole person, taking into consideration physical, mental/emotional and spiritual aspects of the
individual. A number of different approaches are used: Diet and nutritional supplements, botanical medicine,
homeopathy, biotherapeutic drainage, hydrotherapy, acupuncture, injection therapies, allergy desensitization,
and lifestyle counseling.
What to bring to your initial visit: All lab/blood work that has been done within the last year and any
supplements that you are currently taking.
Appointment questions: Should be directed to the front desk. They will gladly reschedule or book your
appointments.
Please be organized: Please arrive 10 minutes before every appointment. If you are late, understand that you
may not get the full allotted time for your appointment. We understand that sometimes situations arise beyond
your control i.e. snow storms, freezing rain, emergencies, etc. and in those circumstances; every effort will be
made to accommodate you. Please bring in all the necessary paperwork to hand in. If you require
photocopying of your records or test results, there will be an additional charge of $0.25 per copy.
Cancellations: Should be made at least 24 hrs in advance (but earlier would be appreciated). A 24-hour
cancellation policy is in effect for all appointments. You can either call the office, or email. To avoid a full
visit charge, please notify the office 24-hours before all scheduled appointments. This is to ensure fairness to
both the physician and patients. This allows us to notify patients that may be on a waiting list.
Scent Free Policy: In order to provide a healthy place of work and care, we have a strict fragrance free policy.
Please ensure that you are not wearing perfume or any strong scents (deodorant, perfume, body wash). Some
patients are extremely allergic to scents, and can have immediate anaphylactic reactions, therefore this policy
must be respected or your appointment can be forfeited.
Return Policy for Supplements: 30 days refund on undamaged, unopened products with original sales
receipt. Returns without the original sales receipt will be issued an account credit. Final sale on any
refrigerated or custom-made items. (ie: Herbal Mix, Pollenguard, Probiotics)
Email: While email is a convenient way to communicate with the office, please be aware that responding to
emails does take time and expertise.
Any emails can be directed through the front desk to
info@hamptonwellnesscentre.com. We try to accommodate questions regarding treatment clarification at no
charge. However, email responses are prioritized for emergencies. Contact us if you have a reasonable
quick/simple question about a supplement, diagnostic test, or a therapy reaction. Anything the doctor deems in
depth will require another appointment. Any discussion of new treatment options or symptoms requires you to
schedule a follow up consultation. All doctors are bound by patient confidentiality and privacy laws and unable
to provide any information that requires access to your patient chart over email. If you have any questions or
concerns that have not been addressed, please book in a scheduled consultation.
I look forward to meeting you! 
Dr. Ashley Kowalski, BSc, ND ● www.ashleykowalskind.com ● Hampton Wellness Centre
1419 Carling Ave, Suite 209, Ottawa, ON, K1Z 7L6 ● 613.761.1600
info@hamptonwellnesscentre.com
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Dr. Ashley Kowalski, BSc., Naturopathic Doctor (ND)
1419 Carling Ave. Suite 209, Ottawa, ON, K1Z 7L6
613.761.1600 - info@hamptonwellnesscentre.com
Please print and complete the following Intake Form and bring it to your first appointment.
Alternatively, you can save the form to your computer and email the completed form to
info@hamptonwellnesscentre.com at least 24 hours in advance of your first appointment.
Adult Naturopathic Patient Intake Form:
Last Name:
First Name:
Middle Name:
Date of Birth:
(DD/MM/YYYY)
Age: Sex:
F / M (circle one)
Occupation:
Contact Information
Full Address (including unit/apartment number):
Postal Code:
Daytime phone
number:
City, Province:
Evening phone number:
May we leave
messages regarding
your visit?
Y / N (circle one)
Email:
1) Last Name:
Emergency Contact Information
First Name:
Daytime Phone Number:
2) Last Name:
Daytime Phone Number:
1) Name:
Relationship:
Evening Phone Number:
First Name:
Relationship:
Evening Phone Number:
Other Healthcare Providers
2) Name:
3) Name:
Specialty/Focus:
Specialty/Focus:
Specialty/Focus:
Phone Number:
Phone Number:
Phone Number:
Dr. Ashley Kowalski, BSc, ND ● www.ashleykowalskind.com ● Hampton Wellness Centre
1419 Carling Ave, Suite 209, Ottawa, ON, K1Z 7L6 ● 613.761.1600
info@hamptonwellnesscentre.com
3
Date of last medical doctor visit:
Date of last physical exam:
Please list regular screening tests performed by other physicians:
How did you hear about this clinic? Why did you choose to come to this clinic?
If referred, please state by whom:
What do you know about our approach?
Have you been treated by a Naturopathic Doctor before? Y / N (circle one)
If yes, by whom?
Date of last visit to ND:
Health Assessment Questionnaire:
In your opinion, what are your most important health concerns? List in order of importance.
1.
2.
3.
4.
5.
6.
7.
8.
How do your conditions/ailments affect you?
What do you think is happening and why?
If you are female, are you pregnant?
Y / N (circle one)
Height:
Current Weight:
Medical History
Are you trying to become pregnant?
Y / N (circle one)
Past Min. Weight:
Past Max. Weight:
Vaccination/ Immunization Record: Please circle all that apply
Dr. Ashley Kowalski, BSc, ND ● www.ashleykowalskind.com ● Hampton Wellness Centre
1419 Carling Ave, Suite 209, Ottawa, ON, K1Z 7L6 ● 613.761.1600
info@hamptonwellnesscentre.com
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Please note vaccinations in bold are considered routine as per the Ontario Childhood Immunization
Schedule 2004:
DPT (Diptheria, Pertussis, Tetanus)
BCG (Tuberculosis)
Pneumococcal conjugate
MMR (Measles, Mumps, Rubella)
Hepatitis A
(Meningitis/Pneumonia)
Gardasil/Cervarix
Hepatitis B
Meningococcal C conjugate
Haemophilus Influenza B
Polio
(Meningitis)
Flu vaccine
Varivax/Varilrix (Chicken Pox)
Other:
Did any of the vaccines cause adverse reactions, if yes please indicate:
Which of the following childhood illnesses have you had? Please circle all that apply
Asthma
Polio
Mumps
Rheumatic Fever
Scarlet fever
Measles
Rubella (German Measles)
Whooping cough
Roseola
Chicken Pox
List any previously diagnosed medical conditions:
Treatment received:
Year:
1.
2.
3.
4.
5.
List all allergies (medications, food, supplements, environmental, etc.)
Reaction Type:
1.
2.
3.
4.
5.
List all prescription drugs (including oral contraceptive, etc.), over-the-counter medications (pain killers,
antacid, etc.), herbs and natural supplements (vitamins, homeopathics, etc.), that you are taking
Medication
Dosage
Start Date
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Please check the meds you currently take: (also indicate how often, or long, each is taken for)
Tylenol-
Tums-
Aspirin-
Anti-acids -
Laxatives-
Diet pills-
Birth control pills-
Implants-
Injections-
Advil-
Dr. Ashley Kowalski, BSc, ND ● www.ashleykowalskind.com ● Hampton Wellness Centre
1419 Carling Ave, Suite 209, Ottawa, ON, K1Z 7L6 ● 613.761.1600
info@hamptonwellnesscentre.com
5
Family Medical History
Include: heart disease, high blood pressure, cancer, diabetes, depression, and other mental illness, drug
and alcohol abuse, kidney disease, arthritis, infertility, headaches, neurological conditions,
hyper/hypothyroid or other relevant information
Age
Health History
Age
Health History
Father
Mother
Grandmother
(Paternal)
Grandmother
(Maternal)
Grandfather
(Paternal)
Grandfather
(Maternal)
Siblings
Children
Review of Systems
Please circle if you have experienced any of the following symptoms, and indicate if they are current
(C=Current) or from the past (P=Past):
General:
Night sweats
Weight loss
Fevers
Excessive thirst
Poor appetite
Weight gain
Fatigue
Bleed or bruise easily
Anemia
Poor sleep
Skin and Hair:
Rashes
Itching
Eczema
Change in moles
Ulcers
Acne
Sweat easily
Chills
Unusual tastes or smells
Heat or cold intolerance
Frequent cold/flu
Change in skin color/texture
Loss of hair
Dandruff
Dr. Ashley Kowalski, BSc, ND ● www.ashleykowalskind.com ● Hampton Wellness Centre
1419 Carling Ave, Suite 209, Ottawa, ON, K1Z 7L6 ● 613.761.1600
info@hamptonwellnesscentre.com
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Head/ Eyes/ Ears/ Nose/ Throat (HEENT):
Headaches/Migraines
Neck masses
Hay fever
Eye pain/ strain
Frequent colds/flu
Blurry vision
Using glasses
Snoring
Heart and Circulation:
Night blindness
Glaucoma
Cataracts
Earaches
Poor hearing
Ringing in ears
Facial pain
Sinus problems
Nose bleeds
Jaw clicks or pain
Tooth pain
Hoarseness
Recurrent sore throat
Mouth sores
High blood pressure
Low blood pressure
Irregular heartbeat
Blood clots
Respiration:
Fainting
Chest pain
Heart palpitations
Varicose veins
Cold hands or feet
Swelling of hands or feet
Deep leg pain
Dizziness
Difficulty breathing
Cough
Bronchitis
Digestion:
Asthma
Wheezing
Production of phlegm
Coughing up blood
Pneumonia
Indigestion/ heartburn
Gas or bloating
Bad breath
Constipation
Poor appetite
Genitourinary:
Abdominal pain or cramps
Nausea
Vomiting
Chronic laxative use
Change in appetite
Rectal pain
Hemorrhoids
Blood or mucus in stool
Diarrhea
Excessive hunger
Frequent urination
Urgency to urinate
Pain on urination
Waking to urinate
Musculoskeletal:
Unable to hold urine
Decrease in flow
Distinctive/ odd color
Blood in urine
Kidney stones
Sores on genitals
Impotence
Neck pain
Back pain
Hand / wrist pain
Shoulder pains
Nervous System/Psychological:
Knee pain
Foot/ ankle pain
Hip pain
Joint pain or stiffness
Broken bones
Muscle weakness
Muscle spasms or cramps
Sciatica
Loss of balance
Quick temper/ irritability
Poor memory
Anxiety
Eating disorder
Depression
Susceptible to stress
Dizziness
Lack of coordination
Addiction
Difficulty concentrating
Seizures
Areas of numbness or tingling
Mood swings
Paralysis
Dr. Ashley Kowalski, BSc, ND ● www.ashleykowalskind.com ● Hampton Wellness Centre
1419 Carling Ave, Suite 209, Ottawa, ON, K1Z 7L6 ● 613.761.1600
info@hamptonwellnesscentre.com
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Female Reproductive: (circle only those that apply when more than one option exists, if applicable)
Irregular periods
Nipple discharge
Pain during intercourse
Vaginal discharge
Breast lumps
Birth control
Heavy flow
Breast tenderness
Gonorrhea/Chlamydia/Syphilis
Clots
Pregnant
Herpes/Genital warts
Period cramps
Sexually active
Yeast infections
Age of first menses: __
Duration of period: __
Days between cycle: __
Date of start of last period: __
Date of last PAP smear: __
Any abnormal PAPS? __
Any pre-menstrual symptoms? If so, describe _____________________________________________
Do you perform monthly self-breast exams? __
Do you use birth control? If so, what type and for how long? _________________________________
Are you currently pregnant? __
Number of pregnancies: ___ # of births: __ # of Miscarriages: __ # of Abortions: __
Male Reproductive: (circle only those that apply when more than one option exists, if applicable)
Penile discharge
Penile sores
Hernias
Testicular pain
Smoker? __
Alcohol use? __
Recreational drug use? ___
Do you exercise regularly?
Do you sleep well?
Testicular masses
Impotence
Premature ejaculations
Prostate disease
Sexually active
Herpes/Genital warts
Gonorrhea/Chlamydia/Syphilis
Yeast infections
General
How many packs/day? __
Years smoked: ____
Type and amount of alcohol/day: ___________________
Type and amount/day: ____________________________
Type and amount/day: ____________________________
Refreshed in the morning? __
# of hours/night: ___
Additional Questions/Information
What three expectations do you have of working with our clinic?
-
Dr. Ashley Kowalski, BSc, ND ● www.ashleykowalskind.com ● Hampton Wellness Centre
1419 Carling Ave, Suite 209, Ottawa, ON, K1Z 7L6 ● 613.761.1600
info@hamptonwellnesscentre.com
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What long-term expectations do you have from working with our clinic?
What expectations do you have of me personally as your physician?
What behaviors or lifestyle habits do you currently engage in regularly that you believe support your
health? Please list below:
What behaviors or lifestyle habits do you currently engage in regularly that you believe are selfdestructive lifestyle habits? Please list below:
What potential obstacles do you foresee in addressing the lifestyle factors which are undermining your
health and in adhering to the therapeutic protocols which I will be sharing with you?
Who do you know that will sincerely support you consistently with the beneficial lifestyle changes you
will be making?
What do you LOVE to do? 
Dr. Ashley Kowalski, BSc, ND ● www.ashleykowalskind.com ● Hampton Wellness Centre
1419 Carling Ave, Suite 209, Ottawa, ON, K1Z 7L6 ● 613.761.1600
info@hamptonwellnesscentre.com
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Is there any other important information that you would like me to know?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Thank you! I look forward to working together to help you.
*A message to all patients:
If you are experiencing a wait-time that is slightly longer than anticipated, I do apologize. I am finishing
up with another patient and I will be with you shortly because YOUR health and time matters. 
Dr. Ashley Kowalski, BSc, ND ● www.ashleykowalskind.com ● Hampton Wellness Centre
1419 Carling Ave, Suite 209, Ottawa, ON, K1Z 7L6 ● 613.761.1600
info@hamptonwellnesscentre.com
10
DECLARATION AND CONSENT TO TREAT
This is to acknowledge that I (or parent/legal guardian) have been informed and understand that:
Naturopathic medicine is the treatment and prevention of diseases by natural means. A naturopathic
intake assesses the whole person, taking into consideration physical, mental/emotional and spiritual
aspects of the individual. A number of different approaches are used: Diet and nutritional supplements,
botanical medicine, homeopathy, hydrotherapy, acupuncture, injection therapies, and lifestyle counseling.
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:



aggravation of pre-existing symptoms
allergic reaction to supplements or herbs
Pain, fainting, bruising, or injury from venipuncture or acupuncture
I agree to pay my full account at the time of each visit or treatment, including fee for services and cost of
supplements and remedies.
I understand that a 24-hour cancellation policy is in effect for all appointments. To avoid a visit
charge, I will notify the office 24-hours before all scheduled appointments. If a cancellation is
received in less than 24 hours, there will be a charge for the FULL follow-up visit fee, which will be
billed automatically to my credit card on file.
I have read and understood the cancellation policy: _____________________________ (Signature)
Privacy of your personal information is an important part of my practice. I understand the importance of
protecting your personal information and your records will be kept confidential.
This consent form is intended to cover the entire course of treatments in this office. I understand that I
am free to withdraw my consent and to discontinue participation in these procedures at any time.
Date: _________________________________
Patient’s printed name: _______________________________________
Patient’s signature: ___________________________________________
Parent’s/legal guardian signature (if under 18 years): ______________________________________
Dr. Ashley Kowalski, BSc, ND ● www.ashleykowalskind.com ● Hampton Wellness Centre
1419 Carling Ave, Suite 209, Ottawa, ON, K1Z 7L6 ● 613.761.1600
info@hamptonwellnesscentre.com