Earthmed Naturopathic Clinic New Patient Forms
ADULT QUESTIONNAIRE
(to be completed by persons 16 years or over)
Date:..............................Name:..............................................................................................................................
Phone (H)..............................................(W)............................................................................................................
Address:........................................................................................................Postal Code......................................
Birth Date:....................... Age:..................Place of Birth:............................................................Sex: F M
Occupation:....................................................Employer:...........................................................................................
Marital Status:................. Name of spouse.................................................................................................................
Number of Children and details (ages, sex)
Contact in case of emergency:........................................................................... Phone:................................................
Please list the names of any Naturopath, Medical Doctor, Chiropractor or other health care
practitioner you are seeing:
When was your last complete physical exam?
How did you find out about the clinic?
Please give me an idea about what your expectations/needs/desires are for this visit, as well as expectations you may have for future visits:
Please list any questions you may have for me regarding my background, education, interests/hobbies, other:
Confidential Patient Information
Please complete this questionnaire as thoroughly as possible. This information will remain confidential.
What is your main reason for attending this office. If this involves a specific health condition, please describe:
What other objectives do you have as far as your health is concerned?
Please rate the following between 0-5, 0= not familiar at all, 5= very familiar (circle)
Please rate how familiar you are with with Naturopathic Medicine.
0 1 2 3 4 5
How familiar are you with Homeopathy?
0 1 2 3 4 5
How familiar are you with Acupuncture?
0 1 2 3 4 5
Current Medications
Please circle which you take or use:
anti-inflammatories/cortisone antacids antibiotics
anti diabetic/insulin antidepressants antifungal
aspirin/Tylenol chemotherapy hormones
high blood pressure meds heart medications laxatives
lithium oral contraceptive radiation
relaxants/sleeping pills thyroid meds recreational drugs
ulcer meds
other (specify):
Hospitalization and/or Surgery
Please detail surgeries, accidents, major illnesses you have had including the date they
occured:
Personal History
Indicate which, if any, of the following conditions you have ever had: (circle)
Abscesses Abortion Alcoholism Allergies
Anemia Arthritis Asthma Cancer
Chicken pox Cold sores Depression Diabetes
Emphysema Elilepsy Frequent colds Gallstones
Genital herpes Gonorrhoea Gout Hayfever
Heart disease Hepatitis HIV Influenza
Kidney disease Leukemia High blood pressure Lyme disease
Malaria Measles Miscarriage Mononucleosis
Multiple sclerosis Parasites Peritonitis Pelvic inflamm.disease
Pleurisy PMS Prostatis Rheumatic fever
Rubella Scarlet fever Sexual abuse Skin disease
Sinusitis Stroke Strep throat Syphilis
Tonsillitis Tuberculosis Typhoid fever Venereal wart
Warts Whooping cough Worms Yellow fever
Other?
Indicate which, if any, of the following items you eat, drink or use (circle):
alcohol aluminum pans hard candy
recreational/hard drugs margarine carbonated beverages
cigarettes purified water refined sugars
coffee/tea microwave saccharine
What do you do for recreation? List your main interests and hobbies.
Are you currently working with a professional counsellor, psychologist, social work, or
other therapist? Please explain.
Family History
Indicate below which ailments have affected your relatives.
RELATIVE................................AGE if alive..........................AGE at death................................AILMENTS.........................
Mother
Father
Brother
Sister
Maternal Grandmother
Maternal Grandfather
Maternal Aunts/Uncle
Paternal Grandmother
Paternal Grandfather
Paternal Aunts/Uncles
Acknowledgement
Please read carefully.
1. I understand that the Doctor, Jennifer Doan, works within the Naturopathic scope of practice, and is not a Medical Doctor; that natural methods of assessment and treatment are used, some of which are not orthodox medical practice at this time.
2. I understand that only those beneficiaries receiving MSP premium assistance (ie less than $20,000 annual) will be entitled to MSP Supplementary Benefits Program for a total of 10 visits per calendar year, including visits for massage therapy, physiotherapy, chiropractic and non-surgical podiatry services. Our office will send in the MSP card and you will be reimbursed within 1-2 months.
3. I have read and understood the fee schedule. I understand all fees must be paid at the time of the visit including services, remedies and supplements and cost of laboratory tests.
4. I understand that there is a charge for appointments cancelled with less than 48 hours notice. The charge is for the full amount for the type of appointment missed. I understand that this fee will be charged to my VISA or credit card when the appointment is missed.
5. I am here as a patient seeking Naturopathic care and am not attending the clinic for any other reason or misrepresenting myself in any way to the practitioner without making my intention known to the Doctor and/or staff.
We greatly appreciate your consideration in this matter.
Date: ___________Patient Signature:_________________________