NATUROPATHIC INTAKE FORM
Name: _________________________________________Today’s Date: ______________________
Address:____________________________ City: _____________ Prov.: _______ PC: _________
Telephone:
(Home)_________________ (Work) ____________________ (Cellphone): _______________
E-mail: _______________________________________ Occupation: ___________________________
Date of Birth: _____________________
Sex: M / F
Where did you first hear about me?
(please be specific: name of friend, website, farmer's market, name of doctor etc)
___________________________________________________________________________________
Emergency Contact Name: _________________________ Relation: ____________________________
Phone: _____________________________________
Other phone: ___________________________
Other Health Care Providers:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
What are your health concerns? Please list in order of importance to you and how long you have been
experiencing them:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
What, if any, measures have you previously taken to help with your health concerns? (circle all that
apply)
Diet changes
Exercise
Osteopathy
Vitamins/minerals
Prescription medication
Massage
Herbs
Acupuncture
Yoga/meditation
Chiropractic
Physiotherapy
Surgery
613-836-7901
|[email protected]
59 Iber Road, Unit 25 Stittsville, Ontario K2S 1E7
Dr Alexis Reid
Previous Medical History ​-​ please list any conditions, illness/injury or hospitalizations:______________
_____________________________________________________________________________________
_____________________________________________________________________________________
Allergies (please list):
_____________________________________________________________________________________
_____________________________________________________________________________________
Medications​ (​please list all current medications):
_____________________________________________________________________________________
_____________________________________________________________________________________
Supplements ​(​please list current supplements):
_____________________________________________________________________________________
_____________________________________________________________________________________
Past prescription medications (please list):
_____________________________________________________________________________________
_____________________________________________________________________________________
Do you frequently take any of the following medications?
Birth control pills
Laxatives
Cold/flu medications
Allergy medications
Cough medications
Tylenol
Ibuprofen
Antacids
Family Medical History ​-​ please indicate which relatives (parents, children, siblings, grandparents) suffer
from the following conditions:
Cancer (which type)
Heart Disease (Heart Attack, Stroke etc)
High Blood Pressure
Thyroid Dysfunction
Diabetes
Gastrointestinal Problems (celiac, Crohn's, etc)
High Cholesterol Asthma
Allergies
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|[email protected]
613-836-7901
59 Iber Road, Unit 25 Stittsville, Ontario K2S 1E7
Dr Alexis Reid
Mental Illness
Autoimmune
How much tobacco do you consume per week? _____________________________
Did you previously consume tobacco? __________ How much and for how long? __________________
How much alcohol do you consume per week? ______________________________
How much caffeine do you consume per week? ______________________________
Do you use recreational drugs? _____________
What type and how often? _________________________
What were the most stressful events in your life?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Do they still affect you now? _____________________________________________________________
What are the major causes of your current stress? (please circle)
Financial
Family
Fertility
Relationship
Career
Unfulfilled expectations
Health
Day-to-day life
How does stress show up for you (get angry, eat more, sleep less, etc)? ____________________________
_____________________________________________________________________________________
Diet ​-​ please describe a typical day's food intake:
Breakfast
___________________________________________________________________________
Lunch
__________________________________________________________________________________
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|[email protected]
613-836-7901
59 Iber Road, Unit 25 Stittsville, Ontario K2S 1E7
Dr Alexis Reid
Dinner
__________________________________________________________________________________
Snacks
__________________________________________________________________________________
Do you have any foods that you do not eat?
__________________________________________________________________________________
Are you a: Meat eater / Vegetarian / Vegan (please circle)
What is your occupation? _______________________________________________________
How many hours a week do you work? ____________________________________________
Do you work shift work? _______________________________________________________
On a scale of 0 to 10 how happy are you with your job (10 = very happy) _________________
What are your main interests and hobbies? __________________________________________________
Do you have time to enjoy them?__________________________________________________________
When do you feel happiest? ______________________________________________________________
Height: _____________Weight: ___________ Max Weight: _________Weight 1 year ago: ___________
Review of Systems (please answer Y = yes, O = occasionally, P = past
Skin:
Eczema
Y
O
P
Rashes
Y
O
P
Hives
Y
O
P
Acne
Y
O
P
Boils
Y
O
P
Itching
Y
O
P
Lumps
Y
O
P
Night Sweats
Y
O
P
Dry skin (year
round/winter
only)
Y
O
P
Y
O
P
Nail changes
Y
O
P
Y
O
P
Moist skin
Changes in mole
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|[email protected]
613-836-7901
59 Iber Road, Unit 25 Stittsville, Ontario K2S 1E7
Dr Alexis Reid
Skin cancer
Y
O
P
Y
O
P
Head:
Headaches
Hair loss
Head injury /
concussion
Y
O
P
Y
O
P
Y
O
P
Y
O
P
Y
O
P
Y
O
P
Y
O
P
Sensitivity to the
sun
Y
O
P
Redness
Y
O
P
Floaters / blind
spots
Y
O
P
Double vision
Y
O
P
Glaucoma
Y
O
P
Cataracts
Y
O
P
Blurring
Y
O
P
Discharge
Y
O
P
Impaired hearing
Y
O
P
Ringing
Y
O
P
Earache
Y
O
P
Vertigo
Y
O
P
Excessive wax
Y
O
P
Infections
Y
O
P
Eyes:
Impaired vision
Glasses / contacts
/ laser surgery
Tearing
Itchy
Dry
Ears:
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|[email protected]
613-836-7901
59 Iber Road, Unit 25 Stittsville, Ontario K2S 1E7
Dr Alexis Reid
Nose:
Frequent colds
Y
O
P
Nose bleeds
Y
O
P
Stuffiness
Y
O
P
Sinus problems
Y
O
P
Allergies
Y
O
P
Frequent sore
throat
Y
O
P
Ulcerations/
cankers
Y
O
P
Gum problems
Y
O
P
Hoarseness
Y
O
P
Cavities
Y
O
P
Bad breath
Y
O
P
Loss of taste
Y
O
P
Cough
Y
O
P
Cough up sputum
Y
O
P
Spit up blood
Y
O
P
Asthma
Y
O
P
Bronchitis
Y
O
P
Pneumonia
Y
O
P
Y
O
P
Difficulty
breathing
Y
O
P
Y
O
P
Last chest ex-ray
Y
O
P
Stroke
Y
O
P
Mouth/Throat:
Respiratory:
Emphysema
Tuberculosis
Cardiovascular:
Heart attack
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|[email protected]
613-836-7901
59 Iber Road, Unit 25 Stittsville, Ontario K2S 1E7
Dr Alexis Reid
Angina
Y
O
P
High blood
pressure
Y
O
P
Murmurs
Y
O
P
Chest pain
Y
O
P
Palpitations/flutter
ing
Y
O
P
Swelling in
ankles
Y
O
P
Increased
cholesterol
Y
O
P
Lumps
Y
O
P
Breasts:
Do you do monthly self-exams?
Pain / tenderness
Nipple discharge
Y/N
Y
O
P
Fibrocystic
breasts
Y
O
P
Y
O
P
Breast cancer
Y
O
P
Abdominal/Gastrointestinal:
Trouble
swallowing
Y
O
P
Change in
appetite
Y
O
P
Y
O
P
Vomiting
Do you strain to have a bowel
movement?
Y/
N
Heartburn
Nausea
Vomiting
blood
Y
O
P
Y
O
P
Y
O
P
Is there undigested food in your bowel
movement?
Y/
N
Blood in stool
Y
O
P
Constipation
Y
O
P
Diarrhea
Y
O
P
Hemorrhoids
Y
O
P
Black, tarry
stools
Y
O
P
Y
O
P
Grey stools
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|[email protected]
613-836-7901
59 Iber Road, Unit 25 Stittsville, Ontario K2S 1E7
Dr Alexis Reid
Belching or
passing gas
Y
O
P
Gall bladder
problems
Y
O
P
Abdominal
pain
Y
O
P
Rectal
bleeding
(blood on
toilet paper)
Y
O
Liver disease
Ulcer
Hernia
Y
O
P
Y
O
P
Y
O
P
How often do you
have a bowel
movement?
P
Is this a change?
Y / N
Urinary:
Pain on urination
Y
O
P
Increased
frequency
Y
O
P
Frequency at
night
Y
O
P
Inability to hold
urine
Y
O
P
Frequent
infections
Y
O
P
Y
O
P
Blood in urine
Y
O
P
Y
O
P
Hesitancy
Y
O
P
Male Reproductive:
Hernia
Testicular pain
Are you sexually
active?
Kidney stones
Urgency
Y
O
P
Testicular mass
Y
O
P
Y
O
P
Y
O
P
Y
O
P
Enlarged prostate
Sexually
Transmitted
Infections
Discharge
Genital rash
Fungal infections
(jock itch/athlete's
foot)
Y
O
P
Y
Y
O
O
P
P
Y
O
P
Sexual difficulties
Y
O
P
Genital sores
Y
O
P
Sexual preference:
heterosexual / homosexual / bisexual
8
|[email protected]
613-836-7901
59 Iber Road, Unit 25 Stittsville, Ontario K2S 1E7
Dr Alexis Reid
Female Reproductive:
Age menses began
O
P
Length of cycle (day 1 to day 1):
Are cycles regular
Y
O
P
Painful menses
PMS
Vaginal discharge
Y
Y
Y
O
O
O
P
P
P
Frequent yeast
infections
Y
O
P
Avg length of
menses (including
Y
spotting)
Last menstrual period Date:
Bleeding between
Y
periods
Excessive flow
Y
Pain during intercourse
Y
Vaginal itching
Y
Fibroids
Y
Number of pregnancies:
Number of miscarriages:
Difficulty
Y
conceiving
Sexual difficulties
Y
Y
Date of last PAP:
Number of live births:
Number of abortions:
Are you sexually
active
Y
O
P
Sexually transmitted
infections
Y
O
P
Genital rash
Y
O
P
Y
O
P
Y
O
P
Y
Y
Y
O
O
O
P
P
P
Y
O
P
Y
O
P
Y
Y
Y
O
O
O
Y
Y
O
O
Neurological:
Fainting
Seizures/convulsion
s
Muscle weakness
Loss of memory
Speech Problems
Endocrine:
Heat intolerance
Problems with
thyroid
Excessive hunger
Excessive sweating
Hormone therapy
Musculoskeletal:
Joint pain
Stiffness
O
P
O
P
O
O
O
P
P
P
O
P
O
P
O
P
Sexual preference:
heterosexual / homosexual /
bisexual
Genital sores
Y
O
Involuntary
movement
Paralysis
P
Y
O
P
Y
O
P
Numbness/tingling
Loss of balance
Brain Fog
Y
Y
Y
O
O
O
P
P
P
Cold intolerance
Excessive thirst
Y
O
P
Y
O
P
P
P
P
Excessive urination
Diabetes
Y
Y
O
O
P
P
P
P
Joint swelling
Arthritis
Y
Y
O
O
P
P
9
|[email protected]
613-836-7901
59 Iber Road, Unit 25 Stittsville, Ontario K2S 1E7
Dr Alexis Reid
Muscle
cramps/spasms
Y
O
P
Backache
Y
O
P
Peripheral Vasculature:
Deep leg pain
Y
Varicose veins
Y
Leg cramps
Y
O
O
O
P
P
P
Y
O
P
Y
O
P
Y
O
P
Y
O
P
Y
O
P
Blood and Lymphatic:
Anemia
Past transfusions
Emotional:
Depression
Anxiety/Nervousnes
s
Phobias
Weakness
Y
O
P
Cold hands/feet
Thrombophlebitis
Extremity ulcers
Y
Y
Y
O
O
O
P
P
P
Y
O
P
Y
O
P
Mood Swings
Tension
Y
O
P
Y
O
P
Insomnia
Y
O
P
Easy
bleeding/bruising
Swollen lymph
nodes
Patient information and Consent Form
Naturopathic treatment is gentle and suitable for people of all ages from newborn to the elderly. At your
first appointment, you can expect a thorough physical examination and history taking which may involve
the ordering of bloodwork or requisition of labs/imaging ordered by your doctor.
Some therapies must be used with caution when dealing with certain conditions (pregnancy/lactation,
heart disease, kidney disease etc). It is very important that you inform your naturopathic doctor of any
conditions you may be suffering from, as well as, update them if you begin to suffer from a new
condition.
You must notify your naturopathic doctor of any forms of medication, herbs, or supplements you are
taking so that they can make sure there are no interactions.
There exists a slight health risk when receiving treatment by naturopathic medicine. These risks
include, but are not limited to, aggravation of pre​-e​ xisting symptoms, allergic reaction to supplements
or herbs, pain, bruising, fainting or injury from acupuncture and puncturing of an organ by
acupuncture needles.
The practitioner will answer any questions you may have to the best of their ability.
While we use our professional skills to do our upmost to help you with your problems, we cannot
guarantee the outcome because every patient is different.
I give permission to contact my doctor(s) to report or gather information on my diagnosis, treatment
plan and progress
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|[email protected]
613-836-7901
59 Iber Road, Unit 25 Stittsville, Ontario K2S 1E7
Dr Alexis Reid
Do you consent to treatment?
Yes
No Your consent may be revoked at any time if you choose.
Signature: _____________________________________
Date: ___________________________
Printed Name: __________________________________
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|[email protected]
613-836-7901
59 Iber Road, Unit 25 Stittsville, Ontario K2S 1E7