Naturopathic Medicine – Intake Form Please complete the following form in order to provide us with the background information we require to ensure you receive comprehensive care. It should take 15-20 minutes. Contact Information: YES I NO Can we send you our seasonal newsletter and monthly calendar of events via email. Your email address will not be shared. How did you hear about the Integrative Health Institute? (If another person, please provide name)
_____________________________________________________________________________ Care Co-ordination: Medical Doctor Please List any other Medical Providers: Integrative Health Institute 46 Sherbourne Street, 2nd Floor I Toronto ON I M5A2P7 I 416.260.6038 Health Priorities / Chief Concerns: List your main heath concerns (or reasons for visiting the clinic) in order of importance
1. ___________________________________________________________________________
2. ___________________________________________________________________________
3. ___________________________________________________________________________
4. ___________________________________________________________________________
Medical History: How would you describe your general state of health? (circle one) excellent good fair poor Medical conditions: Please indicate any serious illnesses, conditions, or reasons for hospitalizations Allergies or Food sensitivities: Please indicate any allergies and/or serious food sensitivities Medications/Supplements: Please list all current medications/supplements Integrative Health Institute 46 Sherbourne Street, 2nd Floor I Toronto ON I M5A2P7 I 416.260.6038 Past Medications/Supplements: Please list all past medications/supplements in the last 5 years.
Have you taken anti-biotics within the last 5 years (circle one)? Yes I No
How many times have you taken anti-biotics within the last 5 years ____________
Were you frequently given anti-biotics as a child? ___________
Vaccinations: Please indicate which vaccinations you have received. Do you use/have any of the following? Integrative Health Institute 46 Sherbourne Street, 2nd Floor I Toronto ON I M5A2P7 I 416.260.6038 Screening Tests: Please indicate which of the following screening tests do you receive (if known)
Are you currently or could you be pregnant: Y I N How many weeks: _____ Have you ever been pregnant? Y I N How many times: _____ How many vaginal births: _____ C-Sections: _____How old were you when you had your first period: ____ Have your periods been regular: _____Have you taken/used (circle all that apply): The birth control pill/when:________ The patch/when:________ An IUD/when:________ Depo Provera injections/when:________ Other: ______________ Are you currently (circle one): Pre-menopausal I Transitioning through menopause I Post-menopausalHave you/are you, taking HRT: Y I N How long: _____
Integrative Health Institute 46 Sherbourne Street, 2nd Floor I Toronto ON I M5A2P7 I 416.260.6038 Family History: Lifestyle Do you identify as: straight homosexual bi-sexual trans-gendered other: ___________________________ Do you have a strong emotional support network: Y I N Who: ________________________________________ Have you experienced any major trauma or loss in the past 5 years? __________________________________ Have you experienced any other trauma or loss in your life? __________________________________________ How would you currently rate your level of stress at this time? Minimal Average Considerable Unbearable What are the major causes of stress in your life at this time: (circle all that apply): financial career personal marriage/relationship health family spiritual other (please elaborate): _____________________________________________________________________________________________ How does your stress manifest itself: _____________________________________________________________ What type of coping mechanism to you employ to manage your stress? _______________________________
What do you do for exercise/movement? (Indicate type, frequency and time of day): _____________________________________________________________________________________________How many hours per night do you sleep: ______ nap: ______ Do you wake rested in the morning: Y I NWhat is your occupation: _________________________ Do you enjoy your work: Y I N I SometimesHow many hours per day do you spend on the following: Driving _____ Watching TV _____ Reading _____ In front of a computer _____ Work _____When was your last vacation: ___________________ Do you actively participate in a spiritual discipline (church, synagogue, meditation, etc…) Y I N
Integrative Health Institute 46 Sherbourne Street, 2nd Floor I Toronto ON I M5A2P7 I 416.260.6038 Dietary Habits What time of day do you eat the following: Breakfast: ______ Lunch: ______ Dinner: _____ Snacks: ______ Do you consume the following (circle all that apply and indicate frequency): Fresh Vegetables: ______ Fresh Fruit: ______ Cold-water Fish: ______ Tuna: ______ canned goods: ______ Pop: ______ Milk: ______ Coffee: ______ Water: ______ Juice: ______ Processed Foods: ______ Microwavable meals: ______ Red meat: ______ Cheese: ______ Chocolate: ______ Aspartame: ______ Deli meats: ______ Fast Food: ______ Do you crave (circle all that apply): Sugar I Chocolate I Salt I Crunchy food I Other: ______________________ Please provide examples of the following: Breakfast: ___________________________________________________________________________________ Snack: ______________________________________________________________________________________ Lunch: ______________________________________________________________________________________ Snack: ______________________________________________________________________________________ Dinner: ______________________________________________________________________________________ Do you have regular bowel movements: Y I N Do you have to strain for a bowel movement: Y I N Do you regularly have loose stools: Y I N Do you associate digestive difficulties with any particular foods: Y I N Which foods: ________________________________________________________________________________ How many bowel movements do you have per day? ____________ Review of Systems Please list conditions or concerns that involve the following systems: SKIN (eg. eczema, psoriasis, hives, rashes) _______________________________________________________ HEAD (eg. headaches) _________________________________________________________________________ EYES (eg. itching, pain, infection, corrective lenses) ________________________________________________ EARS (eg. wax, discharge, hearing impairment) ____________________________________________________ NOSE (eg. sinus problems, pain, nose bleeds) _____________________________________________________ MOUTH (eg. difficult dentition, cavities, loss of taste, problems swallowing) _____________________________ NECK (eg. stiffness, tenderness, hoarseness, tonsillitis, swelling) ______________________________________ HEART (eg. rheumatic fever, murmurs, chest pain) __________________________________________________ LUNGS (eg. cough, asthma, wheezing) ___________________________________________________________ GASTROINTESTINAL (eg. vomiting, swallowing, diarrhea, constipation) ________________________________ URINARY (eg. pain, increased frequency, blood) ___________________________________________________ MALE (eg. hernias, pain or masses in scrotum/testes) _______________________________________________ FEMALE (eg. urgency, menstruation/menarche, discharge, pain or masses in ovaries/uterus ______________ MUSCLE AND SKELETON (eg. joint pain, stiffness, weakness, back pain, fractures) _____________________ NEUROLOGICAL (eg. seizures, paralysis, clumsiness, memory, vision changes, speech problems, sensation alteration) ____________________________________________________________________________________ Integrative Health Institute 46 Sherbourne Street, 2nd Floor I Toronto ON I M5A2P7 I 416.260.6038
• Yes.You can still make an appointment withFor more information about anything in thisyour GP if you feel this is more suitable. • your GP or another member of NHS staff NHS minor • Yes.You can still use other pharmacies to buymedicines or to pick up your prescriptions. • the NHS Helpline on 0800 22 44 88 (calls ailment service at • But remember, you can only use the
Publikationsverzeichnis Prof. Dr. med. Hans Christiansen (Stand 08/2011) 1. Originalarbeiten (insgesamt 71 Originalarbeiten, davon 34 als verantwortlicher Erst- oder Letztautor, kumulativer Impact-Faktor [gelistete Journale]: 218,984 ; durchschnittlicher Impact-Faktor [gelistete Journale]: 3,174 ; die angegebenen Impact-Faktoren beziehen sich jeweils auf das Jahr des E
Naturopathic Medicine – Intake Form
Health Priorities / Chief Concerns:
Past Medications/Supplements: Please list all past medications/supplements in the last 5 years.
Screening Tests: Please indicate which of the following screening tests do you receive (if known)
Family History:
Dietary Habits