Ka Amaru Naturopathic Clinic
Dr. Hania Armengol, B.A., N.D.
Doctor of Naturopathic Medicine
1385 Bank St. Suite 520 Ottawa, Ontario KIH 8N4 Tel. 613/ 249-0053 Fax 613/ 249-0058
E-mail drarmengol@kaamaru.ca web www.kaamaru.ca
Welcome to Ka Amaru Naturopathic Clinic. We look forward to working with you in
achieving your optimum health.
PROCEDURES:
Please fill out the questionnaire as fully and as honestly as possible. Even small details
are important. Mental, emotional and social aspects of your life play a role in your
health. Please feel free to mention any stress that you may have in any of these areas.
Please read the attached article on Naturopathic Medicine. It explains the training and
philosophy of Doctors of Naturopathic Medicine.
At this clinic, emphasis is placed on you accepting responsibility for your health. This
includes informing your practitioner if your program does not suit your needs or
expectations. The more we understand you, the more we can help.
The information given to this clinic is completely confidential.
Thank you for choosing Ka Amaru Naturopathic Clinic.
DECLARATION AND RELEASE:
I __________________________ of the following address, _____________________
_____________________________acknowledge and declare that I have the option of
seeking continuing allopathic (conventional) medical care from a medical doctor and
that naturopathic medical treatments and allopathic medical treatments are different but
not mutually exclusive. I confirm that there has been no suggestion made to me by the
Ka Amaru Naturopathic Clinic or by anyone under its direction or control that I refrain
from seeking or following allopathic medical treatment. I realize that I may
seek/continue all other treatments if I desire.
I also understand that Doctors of Naturopathic Medicine are trained to read and
interpret x-rays, ultrasounds and other conventional medical tests but are restricted
from ordering them in the province of Ontario. Therefore, it is my responsibility to
maintain contact with a Medical Doctor so that all necessary testing may be performed
as required to monitor my condition. Further, I realize that the Doctors of Naturopathic
Medicine in this clinic may use testing procedures that are not conventional and are
used only to make an assessment of the progress of their therapy and is by no means a
tool to accurately diagnose a disease.
I understand that the Doctor of Naturopathic Medicine at the Ka Amaru Naturopathic
Clinic do not treat cancer, autoimmune diseases, genetic diseases, HIV/AIDS, sexually
transmitted diseases, etc., rather they will help me assess and correct the imbalances
in my body, nutrition and lifestyle so that my body can then heal itself.
I also agree to pay my account in full after every visit unless other arrangements have
been made with the Doctor of Naturopathic Medicine at this clinic prior to my visit.
I have also read and understand the fee schedule that was given to me and understand
that the substance or devices prescribed by the Doctors of Naturopathic Medicine at
this clinic may be purchased from the Doctor of Naturopathic Medicine at this clinic, a
pharmacy, a health store, or a medical supply company of my choice A list of stores
that may carry or be able to order the recommended items is available upon request.
Therefore, I hereby give my consent to assessment and treatment by the Doctor of
Naturopathic Medicine at Ka Amaru Naturopathic Clinic.
Dated and signed this _______________ day of _______________ 20____
-----------------------------------------------------Signature
Thank you for taking the time to fill out this form. The information is very important in
the assessment of your case.
NAME: ___________________________________________
DATE:___________________________
ADDRESS: __________________________________CITY: ____________________
PROV.________POSTAL CODE: ____________
PHONE: (H) _____________________ (B______________________
SEX: ______ AGE: ______ DATE OF BIRTH: ______________
BIRTHPLACE:__________________
OCCUPATION: ________________________________HRS PER WEEK: _____
DO YOU LIKE YOUR JOB? _____________
RETIRED?__________WHEN:____________________
HOW MANY WEEKS OF HOLIDAYS DO YOU TAKE PER YEAR?
__________________________
PAST OCCUPATIONS: _______________________________________________
MARITAL STATUS: ____________________ NO. OFCHILDREN: ____________
RELIGION OR PERSONAL PHILOSOPHY: ____________________
FAMILY PHYSICIAN: ______________________________
PHONE: ___________________________
REFERRED BY: _________________________________
WHAT ARE YOUR MAIN HEALTH CONCERNS? (List in order of importance, from
most important to least)
( ) routine check- up: no symptoms
Date problem began:
1, __________________________________________
__________
2.__________________________________________
__________
3.__________________________________________
__________
MEDICAL HISTORY: GENERAL
Date of last physical exam ______ Weight _______________ Height ___________
Maximum Weight __________ When? __________
Energy level (scale 1 - 10: 10 highest) _________
Blood type __________ Date of last blood test ____________
Why?__________________
Do you usually wake up feeling refreshed? _______
Do you have any problems falling asleep? ________
Hrs of sleep/night ____________
Number of times wake up during the night ______________________
Any dental work done before problems started? ____________ When? _______
What? _______________
Number of meals per day? _________Snacks? _______ Vegetarian? ___________
What type _________
Do you smoke now? ________
How many cigarettes per day? __________________________________
Have you ever used recreational drugs? ______
If so, what drugs and for how long _____________________________
Do you drink alcohol? ___________ How many drinks per day _____week______
Do you drink coffee? _____
How many cups per day ___________________________________
Do you have any known allergies? __________
To what ______________________________________
Recent medications & how long taken
_____________________________________________________
Current vitamins and other supplements:
___________________________________________________
Other treatments or health care providers visited in the past:
___________________________________________________________________
_____________________________________________________________________
Type of water that you drink (tap, spring, distilled, etc.):
________________________________________
Do you have any implants or transplants & when placed? (Screws, pins, pacemakers,
silicone, etc.)
_____________________________________________________________________
CHILDHOOD DISEASES: (Please circle)
Measles/ Rubella
Rheumatic Fever
Mumps
Whooping Cough
German measles
Diphtheria
Chickenpox Scarlet Fever
Mononucleosis
Polio
Meningitis
Smallpox
Other
VACCINATIONS: (Please circle)
Pertussis
Rheumatic Fever
Polio
Measles
Mumps
Rubella
Tetanus
Smallpox
Other
Did you have a reaction to any of these vaccinations (e.g. fever)? Y ____ N ____
If yes, what type of reaction?
_____________________________________________________________
X-RAYS: (Please circle)
teeth stomach
gall bladder back chest colon extremities
___________________
EKG? When? __________________ EEG?
BLOOD OR PLASMA TRANSFUSIONS?
other
When? ______________________
When? ___________________
REVIEW OF BODY SYSTEMS: Please circle (Y), if you have the condition now and if
you had it in the past (P).
GENERAL:
Cancer ......................................Y P
Sensitivity to cold.......................Y P
Excessive hair loss....................Y P
Sudden tiredness/weakness....Y P
Fever/Chills..............................Y P
Rapid weight gain/loss.............Y P
Sweat easily/excessively..........Y P
time of day___________________
SKIN:
Rashes................................................Y P
Hives.......................................Y
Psoriasis.............................................Y P
Acne........................................Y
Boils....................................................Y P
Dry Skin..................................Y
Scabies.................................. ............Y P
Lice.........................................Y
New moles, changes in old moles.......Y P
Night Sweats...........................Y
Other ____________________________________ how often?
HEAD:
Headaches...........................................Y P
Injuries...................................Y
Dizziness..............................................Y P
Migraines...............................Y
P
P
P
P
P
P
P
Other
_____________________________________________________________________
EARS:
Discharge.........................................Y P
Itching...............................................Y P
Excess wax.......................................Y P
Infections...........................................Y P
Ringing...................................Y
Earache..................................Y
Hearing loss...........................Y
Loss of balance/vertigo..........Y
P
P
P
P
Other_________________________________________________________________
EYES:
Glasses/contacts? _____ Since when? _______ Prescription changes? ______Near or
Far Sighted_______
Impaired vision.......................Y
Eye pain.................................Y
Double Vision.........................Y
Cataracts................................Y
Redness.................................Y
Light Sensitivity.......................Y
Loss of sight............................Y
P
P
P
P
P
P
P
Tearing or dryness...........................Y
Glaucoma.........................................Y
Itching...............................................Y
Blurring.............................................Y
Blind spot(s)......................................Y
Color blind.........................................Y
Discharge..........................................Y
P
P
P
P
P
P
P
Other_________________________________________________________________
Nose and Sinuses:
Nose bleeds...........................Y
Hay fever...............................Y
Injury......................................Y
Loss of smell..........................Y
P
P
P
P
Stuffiness..............................Y
Allergies................................Y
Sinus problems.....................Y
Obstructions..........................Y
P
P
P
P
Other: ________________________________________________________________
Mouth and Throat:
Hoarseness......................................Y
Grinding teeth or teeth problems.....Y
Gum problems................................ Y
P
P
P
Jaw clicks................................Y P
Sores on lips,tongue,mouth...Y P
Many sore throats...................Y P
Metallic taste in mouth....................Y
P
Dental cavities........................Y
P
Silver fillings________ Gold Crowns__________
Other_______________________________________
Any other metal appliances in the mouth?
What?________________________________________
Other_________________________________________________________________
Neck:
Lump................................................Y P
Goiter......................................Y P
Pain..................................................Y P
Stiffness..................................Y P
Swollen glands.................................Y P
Other_____________________________________
Respiratory:
Chronic or frequent cough................Y
Frequent colds..................................Y
How many yearly?............................Y
Chronic mucous in throat..................Y
Pain on breathing..............................Y
Bronchitis..........................................Y
Chest pain.........................................Y
Coughing blood.................................Y
P
P
P
P
P
P
P
P
Difficulty breathing...................Y
Wheezing................................Y
Asthma....................................Y
Hay fever.................................Y
Shortness of breath.................Y
Emphysema............................Y
Pneumonia..............................Y
Pleurisy....................................Y
P
P
P
P
P
P
P
P
Last chest x-ray_____________ Last tuberculin test_____________
Other____________________
Breasts:
Fibrous tissue....................................Y P
Lumps......................................Y P
Pain...................................................Y P
Tenderness..............................Y P
Do you self examine? ______________________
Other_______________________________________
Cardiovascular:
Heart disease...............................Y
Stroke...........................................Y
Ankle swelling...............................Y
Palpitations/irregular heart beat...Y
Rheumatic fever...........................Y
P
P
P
P
P
Chest pain/angina....................Y
Phlebitis...................................Y
High blood pressure.................Y
Murmurs...................................Y
Last ECG test...........................Y
P
P
P
P
P
Other_________________________________________________________________
Gastrointestinal:
Difficulty swallowing........................Y
P
Diarrhea..................................Y
Food allergies.................................Y
P
Abdominal pain.......................Y
Colitis..............................................Y
P
Appendicitis............................Y
Spitting up blood.............................Y
P
Heartburn................................Y
Rectal bleeding/bloody stool...........Y
P
Change in thirst.......................Y
Hemorrhoids...................................Y
P
Change in appetite...................Y
Black stool......................................Y
P
Change in bowel movements..Y
Jaundice.........................................Y
P
Constipation............................Y
Nausea/vomiting.............................Y
P
Hernias....................................Y
Indigestion/bloating........................Y
P
Hepatitis..................................Y
Belching/gas...................................Y
P
Other_____________________________________
P
P
P
P
P
P
P
P
P
P
Symptoms relieved by eating or worse? ___________________
Number of bowel movements per day_______ Regular? Yes________No_____
Food
Desires/Cravings________________________________________________________
Foods that disagree
____________________________________________________________________
Food aversions________________________________________________________
Urinary:
Pain on urination...............................Y P
Kidney stones.................. Y
Increased frequency..........................Y P
Blood/sugar/pus in urine... Y
Inability to urinate..............................Y P
Frequent infections........
Y
Abnormal thirst..................................Y P
Decrease in flow................... Y
Swelling of hands/feet/ankles...........Y P
Color of urine: pale yellow________ dark___ frothy_____
Bladder/kidney disease or infections Y P
Other_____________________________________
Musculoskeletal:
Joint pain or stiffness........................Y
Arthritis/rheumatism..........................Y
Broken bones....................................Y
Numbness/tingling.............................Y
P
P
P
P
Muscle spasm/cramps..............Y
Weakness.................................Y
Back pain..................................Y
Shoulder pain............................Y
P
P
P
P
P
P
P
P
Other
_____________________________________________________________________
Peripheral Vascular:
Cold hands/feet..................................Y P
Deep leg pain.....................................Y P
Varicose veins..........................Y P
Thrombophlebitis......................Y P
Other_________________________________________________________________
Reproductive:
Sexual difficulties...............................Y P
Chlamydia.................................Y P
Herpes................................................Y P
Syphilis.....................................Y P
Gonorrhea..........................................Y P
Genital infection........................Y P
Non-specific venereal disease...........Y P
Warts on genitals......................Y P
Are you sexually active now? Yes _____ No_____
HIV + Yes____No _____
Sexual preference: Heterosexual______ Bisexual ________ Homosexual _________
Pain during intercourse Yes ____ No____
Increased/decreased sex drive Yes___ No____
Males:
Prostate disease...........................Y
P
Premature ejaculation...............Y P
Impotence.....................................Y
P
Other_____________________________________
Females:
Menopause: Yes____ No____ If Yes-Age _____
Symptoms: ________________________________
Type of birth control________________________
Since when?____________Menses: Regular cycle? Y___ N____
Length of cycle:_______days Duration of flow:________days
Heavy Medium Light Clots Pain or cramps: Y____ N___
Before/after flow starts
First day of last menses_________ No. of miscarriages_______
No. of abortions___________
Complications with pregnancies: Yes ___ No____ Date of last PAP test ________
Vaginal discharge..........................Y
P
Frequent yeast /other infections....Y
P
Other_________________________________________________________________
PreMenstrual Syndrome symptoms:
Depression...................................Y
P
Weight gain...................Y P
Bloating........................................Y
P
Breast tenderness........Y P
Increased appetite.........................Y
P
Other_____________________________________
Neurological:
Fainting.....................................Y P
Loss of memory/poor memory....Y
Areas of numbness/tingling/paralysis...Y P Seizures/Convulsions..................Y
Involuntary movements.............Y P
Loss of balance...........................Y
Muscle weakness......................Y P
Speech problems........................Y
Loss of coordination..................Y P
Hallucinations/mental confusion....... .Y
Concussion/head injury.............Y P
Poor Concentration.............................Y
P
P
P
P
P
P
Other_________________________________________________________________
Endocrine:
Thyroid problems................................. Y
Hormone therapy...................................Y
Diabetes................................................Y
Hypoglycemia........................................Y
P
P
P
P
Other_________________________________________________________________
Blood/lymphatic:
Anemia..................................Y P
Easy bleeding/bruising..........Y P
Lymph node swelling..................Y
Blood transfusions......................Y
P
P
Other_________________________________________________________________
Psycho/Social:
Depression.............................................Y
P
Tension..................................................Y
P
Attempted suicide...................................Y
P
Easily angered/easy to cry.....................Y
P
Mood swings..........................................Y
P
Phobias..................................................Y
P
Anxiety/Nervousness......................... ..Y
P
Sleep problems......................................Y
P
Have you ever had psychiatric-psychological counseling?
______________________________________
How content are you with your life (1-10: 10-very content)_____________________
What would you like to change in your life?________________________________
Do you express your emotions easily? ____________________________
What are the major stresses in your life?__________________________
Alcohol or drug abuse? Y______ N______
Other___________________________________________
HABITS/LIFESTYLE:
Do you participate in sports or have any hobbies that give you relaxation at least 3hrs
weekly?
Yes____ No_____
If yes, what type of activities?_____________________
How many hours?_______________________________
1.____________________________________________________
2.____________________________________________________
3.____________________________________________________
Preferences: Most liked
Least liked
Color......______________________
________________________
Taste.....
______________________
________________________
Climate....
______________________
________________________
Time of day...______________________
________________________
Temperature....______________________
FAMILY HISTORY:
Mother
Cancer
What type
----------------Hereditary
disease What
--------------Skin
allerges/
Hives
--------------Arthritis/
Gout
--------------Kidney
disease
--------------Asthma
--------------Lung
Desease
TB
--------------Liver
disease/
Cirrhosis
--------------Food
Allergies/
Digestive
Problems
Hypoglycemia/
Diabetes
--------------Thyroid/
Obesity
--------------High blood
pressure
--------------Arterioscler
oses/
vascular
disease/
stroke
---------------
________________________
Please check which diseases apply to any blood relative.
Father
Sister
Brother
Grandmother
Grandfather
Others
(who?)
Heart
Attack/
Heart
Disease
--------------Nervous
breakdown
/Epilepsy
--------------Syphilis/
Gonorrhea
--------------Miscarriag
es
Please list in order of appearance from your birth, all hospitalizations, surgeries, diseases, major
accidents, traumas and scars (emotional and physical).
Age _______________________________________________________________
Age_______________________________________________________________
Age_______________________________________________________________
Age_______________________________________________________________
Age_______________________________________________________________
Age_______________________________________________________________
Age _______________________________________________________________
Age _______________________________________________________________
Age_______________________________________________________________
Age _______________________________________________________________
Age_______________________________________________________________
Age______________________________________________________________
Age______________________________________________________________
Age ______________________________________________________________
Age______________________________________________________________
Age______________________________________________________________
Is there anything else that you feel we should know about you?
_________________________________________________________________
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_________________________________________________________________
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