7-2016 Tenth Line Rd.Orléans, ON K4A 4X4
(613) 837-9777www.findfreedom.ca
New Patient Intake Form
Patient Contact Information: Today’s Date:______________________________
Name:_____________________________________
Date of Birth:________________________________Age:__________________Gender:_________________
Health Card #____________________________________________________________
Home Address:____________________________________________________________________________
City:__________________________________________________ Postal Code:________________________
Home Phone #:__________________Work#:______________________Cell#:_________________________
Email:__________________________________________________________________
Can we email you invoices, treatment plans and appointment reminders? Yes No
Preferred method for contact:______________________________
Additional Patient Information:
Occupation:_______________________________Employer:____________________hrs/wk:______________
Marital Status (circle): Single Married Divorced With Partner Widow(er)
Person to call in case of an emergency: _____________________Relationship to you:____________________
Phone number contact for them:________________________________
Name of Family doctor:_______________________________________
Other Physicians you see and their specialties:____________________________________________________
How did you first hear about me?:______________________________________________________________
How did you find my contact information:_______________________________________________________
___________________________ _____________________________ ____________________Patient’s Signature Parent/Guardian’s Signature Date
Chief Health Concerns:List your health concerns in order of importance:1.______________________________________________________________________2.______________________________________________________________________3.______________________________________________________________________4.______________________________________________________________________5.______________________________________________________________________
Past Medical History: Please list diagnosis and treatments you have received: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please list all medications you are presently taking with doses and the date you started taking them: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please list any supplements and herbal medicines you are currently taking (include brands and dosages if known): __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
List all surgeries and hospitalizations including the date occurred:1.___________________________________________ 3.________________________________________2.___________________________________________ 4.________________________________________
Please note when and why you had each of the following:X-rays:________________________________ Accidents:________________________________________MRI/Cat scans:_________________________ Last Eye Exam:____________________________________Ultrasounds:___________________________ Last Dental Visit:__________________________________
Please list all sensitivities/allergies/reactions:Drugs: ______________________________________________________________________________________Foods: ______________________________________________________________________________________Environment: ________________________________________________________________________________
General Health HistoryHeight: _____________________ Weight: ________________ Weight one year ago: ________________Level of stress 1-10:___________ Main causes? ________________________________________________________________________________________________________________________________________________Main interests and hobbies: ____________________________________________________________________Exercise Y/N If so, what kind and how often: __________________________________________________________________________________________________________________________________________________Describe your spirituality: __________________________________________________________________________________________________________________________________________________________________
Dr. Rachel Bell, ND 2016 Tenth Line, Unit 7, Orléans, ON K4A 4X4 (613) 837-9777 [email protected]
Do you restrict any foods from your diet? If so, what foods and why?_____________________________________________________________________________________________________________________________Do you drink coffee Y/N How many cups?_______ Black tea Y/N How many cups?______Do you smoke? Y/N How many cigarettes/day?_______ When did you start smoking?______Do you drink alcohol? Y/N How often and how much?___________________________
Choose Yes, No or Past regarding the use of the following:Antacids Y N P Steroids Y N PAnalgesics Y N P Laxatives Y N P Recreational drugs Y N P Addiction Treatment Y N P
Please circle positive or negative and when you had any of the following:TB Test: Positive / Negative ________________________________________HIV Test: Positive / Negative ________________________________________Hepatitis C: Positive / Negative ______________________________________
Family HistoryPlease list health history of family members including conditions such as cancer (including type), diabetes, celiac, stroke, mental illness, arthritis, asthma, learning disability, allergies, eczema etc. Family Member Age if Alive Age at Death ConditionMotherMaternal GrandmotherMaternal GrandfatherFatherPaternal GrandmotherPaternal GrandfatherSiblings
Review of SymptomsPlease mark any of the symptoms you are currently having with a C, or have had in the past with a P
Dr. Rachel Bell, ND 2016 Tenth Line, Unit 7, Orléans, ON K4A 4X4 (613) 837-9777 [email protected]
Mental / EmotionalC P Treated for Emotional IssuesC P Mood SwingsC P Considered/Attempted SuicideC P DepressionC P Anxiety/NervousnessC P Difficulty ConcentratingC P Seasonal Depression
EndocrineC P HypothyroidC P Hypoglycemia C P Excessive ThirstC P FatigueC P Heat or Cold IntoleranceC P DiabetesC P Excessive Hunger
SkinC P RashesC P AcneC P Colour ChangeC P LumpsC P EczemaC P ItchingC P Perpetual Hair LossC P Night Sweats C P Hives
HeadC P HeadachesC P MigrainesC P Head InjuryC P Jaw / TMJ Problems
NeckC P GoiterC P Swollen GlandsC P Pain or Stiffness
EarsC P Impaired HearingC P Earaches/Impaired BalanceC P Ringing in the EarsC P Jaw / TMJ problems
Nose & SinusesC P Frequent ColdsC P Sinus ProblemsC P Nose BleedsC P HayfeverC P Loss of Smell
Dr. Rachel Bell, ND 2016 Tenth Line, Unit 7, Orléans, ON K4A 4X4 (613) 837-9777 [email protected]
NeurologicC P Seizures or TremorsC P Muscle WeaknessC P Vertigo or DizzinessC P Numbness/TinglingC P Difficulty SleepingC P Loss of Memory
Mouth & ThroatC P Frequent Sore ThroatC P Teeth GrindingC P Gum ProblemsC P Dental CavitiesC P Excessive or Deficient SalivaC P Sore Tongue/LipsC P HoarsenessC P Jaw Clicks
RespiratoryC P CoughC P Spitting up BloodC P AsthmaC P PneumoniaC P EmphysemaC P Pain on BreathingC P Difficulty BreathingC P Shortness of BreathC P SputumC P WheezingC P BronchitisC P Pleurisy
GastrointestinalC P HemorrhoidsC P ConstipationC P DiarrheaC P Blood with StoolC P Abdominal Pain or CrampsC P Gallbladder DiseaseC P Black StoolsC P Colon PolypsC P JaundiceC P Liver Disease
EyesC P Spots in EyesC P Impaired VisionC P Colour BlindnessC P CataractsC P Glasses or ContactsC P Eye Strain/PainC P Tearing or Dryness
UrinaryC P Pain on UrinationC P Increased FrequencyC P Frequent InfectionsC P Frequency at NightC P Inability to Hold UrineC P Kidney Stones
CardiovascularC P Chest PainC P High CholesterolC P Heart DiseaseC P High/Low Blood PressureC P Blood ClotsC P PhlebitisC P Rheumatic FeverC P Swelling in AnklesC P AnginaC P Palpitations/Fluttering
MusculoskeletalC P Joint Pain or StiffnessC P Broken BonesC P Muscle Spasms or CrampsC P ArthritisC P WeaknessC P Sciatica
BloodC P Easy Bleeding or BruisingC P Deep Leg PainC P Varicose VeinsC P AnemiaC P Cold Hands/FeetC P Thrombophlebitis
ImmuneC P Reaction to VaccineC P Chronic Swollen GlandsC P Chronic/Recurrent InfectionsC P Slow Wound Healing
Female ReproductiveC P PMSC P Abnormal PAPC P MiscarriageC P AbortionC P Difficulty ConceivingC P Nipple Discharge C P Breast LumpsC P Sexually Transmitted Disease
Male ReproductionC P Premature EjaculationC P Testicular MassesC P Discharges or SoresC P Sexually Transmitted DiseaseC P Impotence
Review of SymptomsPlease mark any of the symptoms you are currently having with a C, or have had in the past with a P
7-2016 Tenth Line Rd.Orléans, ON K4A 4X4
(613) 837-9777www.findfreedom.ca
CONSENT TO TREAT
Naturopathic medicine is the treatment and prevention of diseases by natural means. Naturopaths assess the whole person, taking into consideration physical, mental, emotional and spiritual aspects of the individual. Gentle, non-invasive techniques are generally used in order to stimulate the body’s inherent healing capacity.
At your first appointment you can expect a thorough medical history and physical examination. Any relevant lab work that is necessary will be ordered or referred for at this time. Because some therapies must be used with caution when dealing with particular conditions (such as pregnancy and lactation, kidney disease, and heart disease), it is very important that you inform your naturopathic doctor imme-diately of any disease that you are suffering from, as well as any forms of medication, drugs, or supple-ments you are taking.
There are some slight health risks to treatment by naturopathic medicine. These include but are not limited to: • Aggravation of pre-existing symptoms • Allergic reactions to supplements or herbs • Pain, bruising or injury from venipuncture or acupuncture • Fainting or puncturing of an organ with acupuncture needles
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 unless so directed by myself unless law requires it. I understand that I may look at my medical record at anytime and can request a copy of it by paying the appropriate fee.
I understand that the results are not guaranteed. I do not expect the Naturopathic Doctor to be able to anticipate and explain all risks and complications.
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) ___________________________________________
Signature of Patient (or Guardian): ____________________________________
Date: ___________________________________________
Naturopathic Doctor: _____________________________________________ Dr Rachel Bell, ND. #2943
Dr. Rachel Bell, ND 2016 Tenth Line, Unit 7, Orléans, ON K4A 4X4 (613) 837-9777 [email protected]
7-2016 Tenth Line Rd.Orléans, ON K4A 4X4
(613) 837-9777www.findfreedom.ca
PRIVACY POLICY FORM
Privacy of your personal information is an important part of your experience with Rachel Bell, Naturopathic Doctor (ND). I understand the importance of protecting your personal information while providing you with high quality naturopathic care. I am committed to collecting, using and disclosing your personal information responsibly.
To demonstrate this commitment to you, please find below an outline of how the office is using and disclosing your information: • Only necessary information is collected about you • I only share your information with your consent • Storage, retention and destruction of your personal information complies with existing legislation and privacy protection protocols. • My privacy protocols comply with privacy legislation and standards of our regulatory body, the College of Naturopaths of Ontario.
HOW MY CLINIC USES, COLLECTS AND DISCLOSES PERSONAL INFORMATION • To assess your health concerns • To provide health care • To advise you of treatment options • To establish and maintain contact with you • To send you newsletters and other information mailings • To remind you of upcoming appointments • To communicate with other treating health-care providers • To allow us to efficiently follow-up for treatment, care and billing • To complete claims for insurance purposes • To invoice for goods and services • To process credit card payments • To collect unpaid accounts • To comply with all regulatory and legal requirements including court orders, statutory requirements to advise authorities of child abuse, reportable diseases and individuals who may be an imminent threat to harm themselves or others
By signing this patient consent form you have given your consent to collection, use and/or disclosure of your personal information as outlined above.
I have reviewed the above information that explains how Rachel Bell, ND will use my personal information and the steps that she is taking to protect my information. I agree that Rachel Bell, ND can collect, use and disclose personal information about me or my child as set out in the above privacy policy.
____________________________________ ______________________________ _____________________Signature Print Name Date
Dr. Rachel Bell, ND 2016 Tenth Line, Unit 7, Orléans, ON K4A 4X4 (613) 837-9777 [email protected]