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Patient History Form

This form can be filled out and submitted online using the submit button at the bottom of the page. Upon reciept of the completed form, you will be contacted regarding an initial appointment.

Intake form

Patient History Form

Name*
First Last
Home Address*
Street Address City Province Postal Code
Telephone
Home*
Work
Cell
Personal Information
Date of Birth*
MM slash DD slash YYYY
Present Age
Place of Birth
If minor, parents' names
Marital Status
- Single
- Married
- Divorced
- Widowed
Occupation
Major Health Concerns
Please List your Present Major Health Concerns* (starting with the most troublesome to you)
Concern
Since
1.*
MM slash DD slash YYYY
2.
MM slash DD slash YYYY
3.
MM slash DD slash YYYY
4.
MM slash DD slash YYYY
5.
MM slash DD slash YYYY
6.
MM slash DD slash YYYY
Other Health Practitioners
Include: family doctor, specialists, physiotherapists, naturopaths, chiropractors, massage therapists, acupuncturists, herbalists, etc.
1.
2.
3.
4.
5.
Please list ALL current medications (Prescription, Non-Prescription, Herbs, Vitamins, etc.). Please put each one on a new line.
Recent lab tests or other investigations:
What do you suspect are the main reasons causing your health problems?*
Family history of:
- heart disease
- strokes
- cancer
- dementia
- other
Significant past surgeries: - medical/dental - what? when?
Do you suffer from frequent infections, now or as a child?*
- yes
- no
If yes, please provide details.
Do you suffer from allergies or asthma, now or as a child?*
- yes
- no
If yes, please provide details.
Have you had a tonsillectomy or appendectomy?*
- yes
- no
If yes, when?
MM slash DD slash YYYY
Have you taken antibiotics frequently?*
- yes
- no
If yes, for what and when?
Do you have amalgam fillings? Dental extractions? Root canals?*
- yes
- no
Do you suffer excess gas production or bowel irregularity?*
- yes
- no
If yes, please provide details.
Current nutrition and any specific diet (e.g. keto, veganism, paleo)
Do you suspect food allergies/intolerances/sensitivities?*
- yes
- no
If yes, please provide details.
What sources of water do you drink?*
- Select All
- tap
- bottled
- filtered
What is your average weekly alcohol consumption?
Beer
number of bottles
Wine
ounces
Hard liquor
ounces
Hard cider
ounces
Do you use cannabis products?*
- yes
- no
If yes, what type?
Current Sleep Patterns
Problems falling asleep*
- yes
- no
- occasionally
Waking up without an alarm*
- yes
- no
- occasionally
Waking up refreshed*
- yes
- no
- occasionally
Regular exercise program
Level of physical activity per week*
Type of exercise
How many covid vaccinations/boosters have you had?*
How many covid infections have you had?*
Other significant infections and types:

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