Name* First Last Home Address* Street Address City ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code TelephoneHome*WorkCellPersonal InformationDate of Birth* MM slash DD slash YYYY Present AgePlace of Birth If minor, parents' names Marital Status Single Married Divorced Widowed Occupation Major Health ConcernsPlease List your Present Major Health Concerns* (starting with the most troublesome to you)ConcernSince1.* 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 PractitionersInclude: 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.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 suspect food allergies/intolerances/sensitivities?* yes no If yes, please provide details.Do you suffer excess gas production or bowel irregularity?* 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?Beernumber of bottlesWineouncesHard liquorouncesHard ciderouncesDo you use cannabis products?* yes no If yes, what type?What do you suspect are the main reasons causing your health problems?
