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.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?Beernumber of bottlesWineouncesHard liquorouncesHard ciderouncesDo you use cannabis products?* yes no If yes, what type? Current Sleep PatternsProblems falling asleep* yes no occasionally Waking up without an alarm* yes no occasionally Waking up refreshed* yes no occasionally Regular exercise programLevel of physical activity per week*Less than 1 hour2-3 hours4-5 hoursMore than 5 hoursType of exercise How many covid vaccinations/boosters have you had?*01-33+How many covid infections have you had?*01-33+unsureOther significant infections and types:
