Adult Naturopathic Intake · 2016-06-24 · Waterdown Clinic of Naturopathic Medicine - Adult Intake Package !!! Page 2 of 8 ! Personal Overview 1. Reversing illness by treating the

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Waterdown Clinic of Naturopathic Medicine (WCNM) 250 Dundas Street E, Waterdown, ON L0R 2H4

905-690-9151 waterdownclinic.com

Naturopathic Intake Form - Adult

Full Name: ______________________________________________ Age ________ Date of Birth _____________ (First) (Middle) (Last) Address________________________________________________________________Postal Code ___________

Phone (home) _____________________ (work &/or cell) ___________________________

E-mail ____________________________________________________________________________________________

Your email will be used for reminder messages and to deliver newsletters and bulletins from the clinic unless declined.

Occupation/Employer______________________________________________ Hours per week ______________

Marital Status: M D W S Sep. # of Children: ___________ Ages & Names :________________________

How did you hear about this clinic? ____________________________ Have you seen an ND in the past? ______ This is a confidential record of your medical history and will be kept in this office. Information contained in

it will not be released to any person unless you authorize me to do so. Emergency Contact

Name______________________________________________ Phone:__________________________________ Relationship__________________________________________ Address:________________________________ Other Key Health Care Providers 1. ______________________________________________________ ( )________________________

2. ______________________________________________________ ( )________________________

3. ______________________________________________________ ( )________________________

Primary health concerns in order of importance: Onset Cause 1. _________________________________________________ __________ _____________________ 2. _________________________________________________ __________ _____________________ 3. _________________________________________________ __________ _____________________ General Height? __________ Weight? _______lbs Maximum Weight? _______ When? _______ Weigh 1 year ago? _______ Time of day when your energy is the best? _____________ and the worst?_____________ Medications (use an extra paper if necessary) List all prescription medications and over the counter medications you currently take. (Please include name of medication and daily dosage) ____________________________________________________________________ ____________________________________________________________________________________________ List past prescription medications._________________________________________________________________ ____________________________________________________________________________________________ List all vitamins, minerals, herbs or other supplements that you take. (Please include name of supplement and daily dosage) _____________________________________________________________________________________ ____________________________________________________________________________________________

Waterdown Clinic of Naturopathic Medicine - Adult Intake Package

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Personal Overview 1. Reversing illness by treating the underlying cause of disease, and effectively managing healthcare

does not happen overnight, it requires a commitment to lifestyle change, and following therapeutic protocols. How would you describe your present level of commitment to making changes in your health? Rate on a scale from 1 to 10, with 10 indicating 100% commitment.

(0%) 0 1 2 3 4 5 6 7 8 9 10 (100%) 2. Please list behaviours or lifestyle habits you engage in regularly that you believe support your health?

_________________________________________________________________________________________ 3. Please list behaviours or lifestyle habits you engage in regularly that you believe undermine your

health?.__________________________________________________________________________________

4. What potential obstacles do you foresee in addressing the lifestyle factors that are undermining your health and in adhering to the therapeutic protocols that I will be sharing with you?_________________________________ _________________________________________________________________________________________

5. What is your support system like? Do you have people who will sincerely and consistently support you with the beneficial lifestyle changes you will be making? __________________________________________________ _________________________________________________________________________________________

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

_________________________________________________________________________________________ Health History How would you describe your current state of health? Excellent Good Fair Poor What was your general state of health as a child? Excellent Good Fair Poor Are you currently being treated for a health care concern by other healthcare practitioners? Please explain. ____________________________________________________________________________________________ ____________________________________________________________________________________________ Have you ever suffered any serious trauma in your life that you feel is still affecting you? ______________________ ____________________________________________________________________________________________ Do you have any known contagious diseases at this time? ! Y ! N If yes, what? _________________________________________________________________________________ Please indicate any serious conditions, illnesses, injuries, surgeries, and/or hospitalizations that you have had. Include approximate dates. ______________________________________________________________________ ____________________________________________________________________________________________ List any X-rays, CT scans, blood work or other studies that you have had in the past year._____________________ ____________________________________________________________________________________________ May we requisition these for our records? ! Yes ! No

Allergies Do you have any drug allergies/reactions?__________________________________________________________ Please list any foods, environmentals, chemicals or supplements you sensitive or allergic to: __________________ ____________________________________________________________________________________________ Have you ever had an anaphylactic reaction? _______________________________________________________ Sleep Do you sleep soundly? ! Yes ! No Do you fall asleep easily? ! Yes ! No Do you wake refreshed? ! Yes ! No Do you wake during the night? ! Yes ! No How often?______


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Do you fall back to sleep easily? ! Yes ! No Do you have a regular sleep routine? ! Yes ! No What Immunizations have you had? � DPT (diphtheria, pertussis, tetanus) � Hepatitis A � Flu shot � Haemophilus influenza B � Hepatitis B � Polio � MMR (measles, mumps, rubella) � Hepatitis C � Smallpox � Chicken pox � Other: ______________________________

Please indicate any adverse reactions you have experienced from an immunization._________________________ ____________________________________________________________________________________________ Family History by Relative: Age if living Age at Death Ailment(s) Mother Father Sisters Brothers Maternal Grandmother Maternal Grandfather Maternal Aunts/Uncles Paternal Grandmother Paternal Grandfather Paternal Aunts/Uncles Lifestyle What is your general outlook on life? ______________________________________________________________ Main interests and hobbies _____________________________________________________________________ Do you exercise? ! Y ! N What do you do and how often? _______________________________________ Do you spend time outdoors? ! Y ! N How much? _______________________________________________ What do you do regularly for rest, relaxation and fun? _________________________________________________ Are you regularly exposed to toxins or other hazards (work, home, hobbies, etc.)? Please describe._____________ ____________________________________________________________________________________________ How would you describe the emotional climate of your home? __________________________________________ How stressful is your life? How well do you handle these stressors?______________________________________ ____________________________________________________________________________________________ For the following, circle “Y” for yes, “N” for no, or “P” for in the past. Do you use recreational drugs? -Which drugs?

Y N P Do you have a religious or spiritual practice? Y N

Do you drink alcohol? - How many per week?

Y N P Do you watch television? How many hours per week?

Y N

Have you ever been treated for addiction? Y N P Exposed to 2nd hand smoke? Y N P Do you eat refined sugar? Y N P Do you enjoy your work? Y N Do you add salt to your food? Y N P Do you take vacations? Y N Do you drink cola/soft drinks? - How much per day?

Y N P Do you drink coffee? - How many cups per day?

Y N P

Do you smoke tobacco? - How much?_______ How Long?______

Y N P Do you eat out often? Y N P

Do you eat three meals a day? Y N P Did you have antibiotics often as a child? Do you drink black tea? - How many cups per day?

Y N How often have you had antibiotics in last year?

Y N


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Review of Systems

Please indicate whether you experience, or have experienced in the past, any of the following. Skin Eczema, hives? Y N P Lumps? Y N P Acne, boils? Y N P Hair loss? Y N P Itching? Y N P Dryness? Y N P Colour change? Y N P Night sweats? Y N P Temperature change? Y N P Change in a mole? Y N P Head/Neck Headaches? Y N P Head Injury? Y N P Migraines? Y N P Jaw/TMJ problems? Y N P Goiter Y N P Swollen glands? Y N P Eyes Glasses/contacts? Y N P Double/blurred vision? Y N P Eye pain? Y N P Spots in vision? Y N P Tearing or dryness? Y N P Itching/redness? Discharge? Y N P Glaucoma? Y N P Sensitive to the sun? Y N P Ear/Nose/Throat Impaired hearing? Y N P Ringing? Y N P Frequent earaches? Y N P Vertigo? Y N P Discharge from ears? Y N P Infections? Y N P Sinus problems? Stuffiness? Y N P Nose bleeds? Y N P Frequent sore throat? Y N P Seasonal allergies? Y N P Teeth grinding? Y N P Loss of smell or taste? Y N P Gum problems? Y N P Frequent canker sores? Y N P Amalgam fillings? Y N Hoarseness? Y N P Immune Chronically swollen glands? Y N P Chronic infections? Y N P Frequent cold/flu Y N P Slow wound healing? Y N P Respiratory Lingering cough? Y N P Tuberculosis? Y N P Spitting up blood? Y N P Asthma? Y N P Spitting up anything else? Y N P Wheezing? Y N P Pneumonia? Y N P Bronchitis? Y N P Emphysema? Y N P Shortness of breath? Y N P Gastrointestinal Trouble swallowing? Y N P Change in thirst? Y N P Nausea? Y N P Change in appetite? Y N P Vomiting? Y N P Heartburn/ Indigestion? Y N P Vomiting blood? Y N P Constipation? Y N P Blood in stool? Y N P Diarrhea? Y N P Abdominal pain or cramps? Y N P Worms/Parasites? Y N P Belching or passing gas? Y N P Gall bladder disease/stones? Y N P Black, tarry stools? Y N P Ulcer? Y N P Jaundice (i.e., yellow skin)? Y N P Hemorrhoids/fissures? Y N P Liver disease? Y N P Hernia? Y N P Bowel movements – how often? Change in bowel movements? Y N P


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Cardiovascular High blood pressure? Y N P Angina? Y N P Low blood pressure? Y N P Murmurs? Y N P Fainting? Y N P Blood clots? Y N P Past ECG (Echocardiogram)? Y N P Palpitations/fluttering? Y N P Rheumatic fever? Y N P Chest pain? Y N P Swelling in ankles? Y N P Urinary Pain on urination? Y N P Frequent infections? Y N P Increased frequency? Y N P Inability to hold urine? Y N P Urination at night? Y N P Kidney stones? Y N P Urgency or hesitancy? Y N P Blood in urine? Y N P Musculoskeletal Joint pain or stiffness? Y N P Weakness? Y N P Broken bones? Y N P Sciatica? Y N P Muscle spasms or cramps? Y N P Backache? Y N P Joint swelling? Y N P Neck pain/stiffness? Y N P Mental/Emotional Treated for emotional issues? Y N P Memory problems? Y N P Mood swings? Y N P Anxiety or nervousness? Y N P Poor concentration? Y N P Depression? Y N P Tension and/or stress? Y N P Considered/attempted suicide? Y N P Phobias? Y N P Seasonal depression? Y N P Male Reproductive Hernias? Y N P Prostate enlargement or disease? Y N P Testicular pain or masses? Y N P Discharge or sores? Y N P Are you sexually active? Y N P Chlamydia?/ Gonorrhea Y N P Impotence? Y N P Herpes? /Syphilis? Y N P Premature ejaculation? Y N P Genital warts? Y N P Do you use birth control? What type?

Y N P

Female Reproduction/Breasts Age at first menses? Difficulty conceiving? Y N P Age at last menses? (menopausal) Cervical dysplasia? Y N P Typical duration of bleed? days Pain during intercourse? Y N P Typical length of cycle? days Number of pregnancies? Are cycles regular? Y N P Number of live births? PMS? Y N P Number of miscarriages? Painful menses? Y N P Number of abortions? Heavy or excessive flow? Y N P Menopausal symptoms? Y N P Bleeding between periods? Y N P Chlamydia?/ Gonorrhea Y N P Clotting during menses? Y N P Herpes?/ Syphilis? Y N P Are you sexually active? - Type of birth control?

Y N P Genital warts? Y N P

Date of last PAP? Unusual vaginal discharge? Y N P Abnormal PAP? Y N P Do you do breast self-exams? Y N P Endometriosis? Y N P Breast pain or tenderness? Y N P Ovarian cysts? Y N P Breast lumps? Y N P Have you had a mammogram? Y N P Nipple discharge? Y N P


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Endocrine Fatigue? Y N P Heat or cold intolerance? Y N P Excessive thirst? Y N P Hypoglycemia? Y N P Excessive hunger? Y N P Excessive sweating? Y N P Excessive urination? Y N P Hormone Therapy? Y N P Blood/Peripheral Vascular Easy bleeding or bruising? Y N P Anemia? Y N P Deep leg pain? Y N P Cold hands/feet/other? Y N P Varicose veins? Y N P Extremity swelling? Y N P Extremity numbness? Y N P Extremity ulcers? Y N P Neurologic Seizures/convulsions? Y N P Numbness or tingling? Y N P Muscle weakness? Y N P Speech problems? Y N P Vertigo? Y N P Loss of balance? Y N P Paralysis? Y N P Involuntary movement? Y N P Is there anything else that you would like to add or comment on?____________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________

Thank-you for your time and effort.

This information will assist in providing you with quality naturopathic health care.

Consent for Personal Information Our privacy policy can be viewed in full at www.waterdownclinic.com

I understand that to provide me with Naturopathic services, our naturopathic doctors will collect some personal information about me. For example; address, phone number and health history. I understand that the information I have provided here will be kept confidential within the WCNM, unless otherwise authorized by me, I have reviewed the clinic’s Privacy Policy about the collection, use and disclosure of personal information, steps taken to protect the information, and my right to review my personal information. I understand how the Privacy Policy applies to me. I have been given a chance to ask any questions I have about the Privacy Policy, and they have been answered to my satisfaction. I understand the following: My email will be used for reminder messages and to deliver newsletters and bulletins from the clinic and that I can decline or unsubscribe at any time. My email will never be sold or shared with unauthorized third parties. That, as explained in the Policies and Procedures for Personal Information, there are some rare exceptions to these commitments. I agree to the doctors at WCNM. using and disclosing personal information about me as set out above and in the above mentioned Privacy Policy. Signature: ______________________________________Printed Name: _______________________________ Date: _____________________


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Informed Consent Teri A. Jaklin BA, ND

We want your informed consent for the services we are to provide. This means that we want you to understand the service as we provide, the cost involved, and what we do with the personal information we obtain about you. If you have any questions about this, please ask. Naturopathic Medicine is the restoration/maintenance of health and prevention of disease by natural means. Naturopathic Doctors assess the whole person, taking into consideration physical, mental, emotional and spiritual aspects of the individual. The following outlines the therapies we may utilize in developing your individualized treatment plan: Individual diet and nutritional supplements are recommended to address deficiencies, treat disease processes, and promote health. Botanical medicine is a plant-based medicine that involves the use of herbal teas, tinctures, capsules, and other forms of herbal preparations for the treatment of illness and disease. Homeopathy is a form of medicine based on the use of tiny doses of the very thing that causes symptoms in healthy people. These minute doses of plant, animal, or mineral origins are used to stimulate the body’s ability to heal itself. We use homeopathic medicine alone and in combinations. Acupuncture refers to the insertion of fine, sterilized disposable needles through the skin into underlying tissues at specific points on the body to relieve symptoms and restore balance to the body. Physical medicine refers to the use of hands-on techniques such as soft tissue work and spinal manipulation, although we do not use spinal manipulation as a treatment modality. Hydrotherapy refers to the use of hot/cold water applications to improve circulation and stimulate the immune system. Lifestyle counselling involves identifying risk factors and obstacles and then making recommendations to help optimize one’s physical, mental and emotional environment. During your initial visits, your Naturopathic Doctor will take a thorough case history and perform a basic/complaint-oriented physical examination. Existing blood, and imaging reports are helpful and, when indicated, the doctor may recommend further testing. Even the gentlest therapies may cause complications in certain physiological conditions. This depends greatly on the individual and the extent of the illness. It is very important, therefore, that you inform your Naturopathic Doctor immediately of any disease process that you are suffering from, as well as any medications (prescription or over-the-counter) that you are taking. If you are pregnant, suspect you are pregnant, or you are breast-feeding, advise your doctor immediately. Health risks associated with Naturopathic Medicine include but are not limited to:

• Aggravation of pre-existing symptoms during the healing process. • Allergic reactions to supplements or herbs. • Pain, bruising or injury from venipuncture or acupuncture. • Fainting or puncturing of an organ with acupuncture needles. • Muscle strains and sprains or disc injuries from spinal manipulation (not applicable to treatment by T. Jaklin)


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Informed Consent Waterdown Clinic of Naturopathic Medicine

______ Initials

I understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others without my consent, unless required by law. I understand that I may look at my medical record at any time and can request a copy, by paying the appropriate fee. I have read and understand the privacy policy of the WCNM.

______ Initials

I understand that the Naturopathic Doctor will answer any questions that I have to the best of her ability. I understand that the results are not guaranteed. I do not expect the doctor to be able to anticipate and explain all risks and complications. I voluntarily consent to the diagnostic and therapeutic procedures mentioned above, except for (please list any exceptions):

______ Initials

I understand that any treatment or advice provided to me by my Naturopathic Doctor is not mutually exclusive of any treatment or advice that I may be receiving now or in the future from another licensed health care provider.

______ Initials

I understand the fee schedule as stated below.

______ Initials

I understand that I am at liberty to seek or continue medical care from a physician or surgeon or other health care provider qualified to practice in Ontario. Dr. Teri Jaklin, N.D. has not suggested or recommended that I refrain from seeking or following the advice of another licensed health care provider.

______ Initials

I understand that I may purchase any recommended medicines or supplements from the dispensary of the Waterdown Clinic of Naturopathic Medicine OR any pharmacy/retail store of my choice.

Fees and Payment As the patient, you are responsible for the total charges incurred (visit fees plus any supplements or medicinal substances) for each visit. Payment is due at the time of service. If you have extended benefit coverage for Naturopathic Medicine, you are responsible for billing your own insurance company. Most insurance companies do not cover the supplements that we prescribe and dispense. Fee Schedule – All fees for products and services subject to HST Consultations Initial Consult

60 minutes Second Consult 60 minutes

Repeat Consult 30 minutes

Repeat Consult 15 minutes

Adult (14-65 yrs of age) $169.00 $169.00 $80.00 $40.00 Child (0-13 yrs of age) $135.00 -- $65.00 $30.00 Senior (65yrs+) $150.00 $150.00 $75.00 $35.00 Acupuncture $100.00 (45 mins) - Acute Telephone Fee $25.00 up to 10 min consultation

I understand that 24 Hour Notice is required for cancelation of an appointment and that I am otherwise responsible for payment of the appointment. I understand that I will receive an email (or telephone if no email available) reminder at least 48 hours prior to my appointment. I have read and understand the above-stated information. I intend this consent form to cover the entire course of treatment for my present condition. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time. Patient Name (please print): _____________________________________ Date: _______________________ Signature of Patient (or Guardian): ____________________________________________________________

Adult Naturopathic Intake · 2016-06-24 · Waterdown Clinic of Naturopathic Medicine - Adult Intake Package !!! Page 2 of 8 ! Personal Overview 1. Reversing illness by treating the

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