New Patient Intake Form

PERSONAL INFORMATION
Name ____________________________________ Date of First Visit _____________________
Address ________________________________________________________________________
City ____________________________ Province ____________ Postal Code _____________
Telephone # (home)_________________________ (work)______________________________
E-mail Address __________________________________ Relationship Status _______________
Age _____ Date of Birth (M/D/Y)__________________ Gender: female ____ male ____
Occupation ___________________Hours per week ______ Employer_____________________
Has any other family member already been a patient at the clinic? _______________________
Next of Kin or other to reach in an emergency ________________________________________
Relationship _____________________ Phone _________________________________________
HEALTH OVERVIEW
Name of current general practitioner (MD) __________________________________________
GP’s contact information _________________________________________________________
When was your last visit to your GP? _______________________________________________
What was the reason? ____________________________________________________________
Are you seeing a medical specialist? Y N
If yes, for what reason? ____________________________________________________________
Name of medical specialist __________________________________________________________
Do you have any known contagious diseases at this time? Y N If yes, what?________________
What is the main reason for your visit today?__________________________________________
________________________________________________________________________________
What are your most important health problems? List as many as you can in order of importance.
1.
2.
3.
4.
5.
6.
How did you hear about our clinic? ________________________________________________
Consent and Cancellation Policy
I hereby consent to receive treatment by Dr Jason Hughes of Maple Ridge Naturopathic Clinic. I understand that
I am responsible for paying the full cost of treatment if I do not give 24 hours notice of change or cancellation.

Signature: _________________________________ Today’s date: ___________

(Parent or Guardian if a minor)
HEALTH HISTORY QUESTIONNAIRE

FAMILY HISTORY
Do you have a family history of any of the following (please circle)?
Cancer Diabetes Heart Disease
Kidney Disease Epilepsy High Blood Pressure
Tuberculosis Stroke High Cholesterol
Asthma / Hayfever / Hives Arthritis Anemia
Any other relevant family history? _____________________________________________________
___________________________________________________________________________________
What is your ethnic heritage?__________________________________________________________
CHILDHOOD ILLNESSES
Scarlet Fever Diphtheria Rheumatic Fever
Mumps Measles German Measles

IMMUNIZATIONS
Polio Pertussis
Tetanus shot: when?______________ Diphtheria
Measles / Mumps / Rubella Travel Related:

HOSPITALIZATIONS, SURGERIES, IMAGING

What hospitalizations or surgeries, X-rays, CAT scans, EEG, EKG’s have you had?
_________________________ year:_______ ___________________________ year: _________
_________________________ year:_______ ___________________________ year: _________
_________________________ year:_______ ___________________________ year: _________
_________________________ year:_______ ___________________________ year: _________

ALLERGIES / SENSITIVITIES
Are you hypersensitive or allergic to...
Any drugs? ________________________________________________________________________
Any foods? ________________________________________________________________________
Any environmentals or chemicals? _____________________________________________________

CURRENT MEDICATIONS
Do you take or use?
Laxatives Y N Pain relievers Y N Antacids Y N
Cortisone Y N Appetite suppressants Y N Antibiotics Y N
Tranquilizers Y N Thyroid medication Y N Sleeping pills Y N

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Please list any prescription medications, over the counter medications, vitamins or
other supplements you are taking?
1) _________________________________ 5) _________________________________
2) _________________________________ 6) _________________________________
3) _________________________________ 7) _________________________________
4) _________________________________ 8) _________________________________

GENERAL
Height Weight _________ lbs. Weight 1 year ago ________lbs.
Max Weight Ibs. When _________ Min Adult Weight ______ Ibs When ____________
When during the day is your energy the best? worst?

REVIEW OF SYSTEMS
Check () any of the following conditions you currently have (C), or have had in the past (P).
Please also check if you feel any of the following are a significant part of your medical history.

C P LIFESTYLE
Alcohol History of Smoking
Marijuana - How many packs per day?
Drugs - How many years?
Treated for drug dependence Occupational Hazards
Stress Any major traumas

MENTAL/ EMOTIONAL
Treated for emotional problems Depression
Mood swings Anxiety or nervousness
Considered/attempted suicide Tension
Poor Concentration Memory problems

ENDOCRINE
Hypothyroid Heat or cold intolerance
Hypoglycemia Diabetes
Excessive thirst Excessive hunger
Fatigue Seasonal depression

IMMUNE
Chronic fatigue syndrome Chronic infections
Chronically swollen glands Slow wound healing
Reactions to vaccines Reactions to immunizations

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 NEUROLOGIC
Seizures Heat or cold intolerance
Muscle weakness Numbness/tingling of extremities
Tremor Loss of memory
Vertigo or dizziness Difficulty Concentrating

SKIN
Rashes Eczema, Hives
Acne/boils Itching
Color change Perpetual hair loss
Lumps Night sweats

HEAD
Headaches Head injury
Migraines Jaw/TMJ problems

EYES
Spots in eyes Cataracts
Impaired vision Glasses or contacts
Blurriness Eye strain/pain
Color blindness Tearing or dryness
Double vision Glaucoma

EARS
Impaired hearing Ringing in the ears/Tinnitus
Earaches Dizziness

NOSE AND SINUSES

Frequent colds Nose bleeds
Stuffiness or post-nasal drip Hayfever
Sinus problems Loss of smell

MOUTH AND THROAT

Frequent sore throat Copious saliva
Teeth grinding Sore tongue/lips
Gum problems Hoarseness
Dental cavities Jaw clicks

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 NECK
Lumps Swollen glands
Goiter Pain or stiffness

RESPIRATORY
Cough Sputum
Spitting up blood Wheezing
Asthma Bronchitis
Pneumonia Pleurisy
Emphysema Difficulty breathing
Pain on breathing Shortness of breath
Shortness of breath at night Shortness of breath lying down

CARDIOVASCULAR
Heart disease Angina
High/low blood pressure Murmurs
Blood clots Fainting
Phlebitis Palpitations/Fluttering
Rheumatic fever Chest pain
Swelling in ankles High Cholesterol

GASTROINTESTINAL
Trouble swallowing Constipation
Reflux Diarrhea
Heartburn Blood with stool
Vomiting blood Change in bowel movements
Nausea Abdominal pain or cramps
Change in appetite Gallbladder disease
Vomiting Black stools
Belching or passing gas Colon Polyps
Ulcer Jaundice
Hemorrhoids Liver disease

URINARY
Pain on urination Frequency at night
Increased Frequency Inability to hold urine (urgency)
Frequent infections Kidney stones

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 MUSCULOSKELETAL
Joint pain or stiffness Arthritis
Broken bones Weakness
Muscle spasms or cramps Sciatica

BLOOD/PERIPHERAL VASCULAR
Easy bleeding or bruising Anemia
Deep leg pain Cold hands/feet
Varicose veins Thrombophlebitis

FEMALE REPRODUCTION/BREASTS
Age of first menses Length of cycle _____________________________
Duration of Menses ____________ Age of last menses (if menopausal) _____________
Date of last annual exam/ PAP (M/D/Y) ____________________________________________
Irregular cycles Abnormal PAP
Bleeding between cycles Cervical Dysplasia
Cramping with menses Endometriosis
Premenstrual Syndrome Ovarian cysts
Clotting Uterine Fibroids
Heavy or excessive flow Sexually Active
Vaginal Discharge Painful Intercourse
Menopausal Symptoms Sexual difficulties
Breast lumps Sexually Transmitted Disease
Breast pain/tenderness Birth Control: type ____________
Nipple discharge Difficulty conceiving

Number of pregnancies Number of live births _____________________________

Number of miscarriages _______________ Number of abortions ____________________________
Do you do breast self exam? _________________________ Have you had a hysterectomy?_________
MALE REPRODUCTION
Hernias Sexually Transmitted Disease
Testicular masses Discharge or sores
Testicular pain Impotence
Prostate disease Premature ejaculation
Sexually Active Birth Control: Type ___________

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 CONTEXT OF CARE

What expectations do you have from this visit to our clinic?

What long-term expectations do you have from working with our clinic?

What expectations do you have of me personally as your physician?

Thank you for your time in providing this information.

We look forward to serving you in the best ways we are able.