Naturopathic Doctors - Calgary, Edmonton, Vancouver - Naturopathic Medical Clinic

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Your Forms

Patient Intake Form

The patient intake form for new patients is now available here online. We ask that you take the time to fill it out as completely as possible so that the clinician will be able to review your overall healthfulness before your appointment.

QB

Forms:

Letter to New Patients - Dr. Schaplowsky (click here)
Patient Intake Form (click here)
Financial Policy (click here)
Consent for Communication and Privacy Policy (click here)
Consent for use of Patient Portal (coming soon!)

Send:

e-mail: clinic@alpineHEALTH.ca
fax: Attn: alpineHEALTH @ 780.438.1601
mail:

                       alpineHEALTH
                       288, 6005 Gateway Blvd.
                       Edmonton AB T6W 1J7

Book your appointment today ... Discover the natural you!

New Patient Intake Form

If you have not been seen by one of our physicians in the last 12 months, we ask you to fill out this form.

* Indicates required field

Name *

First

Last

Date of Birth *

Sex *

Provincial Health Care Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone Number *

Cell Phone Number *

Work Phone Number *

Email *

Emergency Contact *

First

Last

Emergency Contact - Phone Number *

How did you hear about our Doctors? *

Health History:

When, where and by whom did you last receive medical *

In your opinion, what are your most important physical, emotional, or mental health problems? Indicate which is/are of the most immediate concern to you.

Concern 1 *

Concern 2 *

Concern 3 *

Concern 4 *

How would you rate your overall health? *

What are your expectations for a first visit *

What are your expectations for our work together in general? *

What hospitalizations or have you had? When did they occur? *

When were your last lab tests or imaging performed? *

Blood Type *

Medications - list all medications, herbal supplements,vitamins presently taking and the dosage *

Allergies - List all allergies to food, medications, supplements, pets, environment. *

What happens when you experience an allergy attack? *

As a child did you frequently experience (check all that apply)? *

Asthma Ear Infections Excema/Psoriasis Continual Runny Nose

Any difficulties with your birth or while your mother's pregnancy with you? *

Other immunizations - either for travel or as a member of the Armed Forces *

Family History: Please List ages, any major health problems, and if deceased, what they died from and at what age.

Mother *

Father *

Siblings *

Mother's Mother *

Mother's Father *

Father's Mother *

Father's Father *

Social History

Select One *

Untitled *

With whom do you live? *

Are you: *

Comment *

Faith - what is your faith practice? *

Please list the most significant stressful events of your life (remember to include childhood). *

Health Habits

Alcohol: indicate which you drink. *

Wine Beer Hard Alcohol None

Number of Drinks per week *

Smoking: Have you/or do you currently smoke? *

If you currently smoke - how many cigarettes/day do you smoke? *

Recreational Drugs: Have you or do you currently use recreational drugs? *

If you have used drugs, which ones, how often and for how long? *

How many times do you exercise for 1 hour or more a week? *

Relaxation: How often druing the day or before bed do you relax in a week? *

What do you do to relax, ex. hobbies, TV, reading, etc.? *

Diet

Number of meals eaten at home/week. *

Number of meals eaten at a fast food resturant/week. *

List the primary foods in your diet (including snacks). *

What foods are excluded from your diet and why? *

What foods do you crave and when? *

Are you satisifed with your current diet? *

completey somewhat not at all

Sleep

How many hours a night sleep do you get? *

Home Environment and Other Environmental Exposures

Female Reproductive Health (Skip to the next section if you are male)

Hormone Replacement Therapy: *

No Yes - Bioidentical homrones Yes - Hormones Yes - Herbals

Age mestrual periods began: *

Do you have a history of an abnormal pap? *

Yes No Not sure Not Applicable

Do you suffer from PMS? *

Yes No Not Applicable

Hiow many days long is your cycle? *

Is your period normal? If not please describe. *

Are you currently sexually active? *

Yes No

Have you had a PAP in the last 12 months? *

Yes No

Sexual Desire (0=no desire) *

Any sexual problems: *

Breasts: have you had or currenlty have any of the following (check all that apply)? *

Male Reproductive Health

Are you currently sexually active? *

Yes No

Sexual Desire (0=no desire) *

Any sexual problems? Explain *

Medical History

Energy: Which of the following do you currently suffer from (check all that apply) *

Fatigue Hyperactivity None of the above

Urinary: Which of the following do you currently suffer from (check all that apply)? *

Overall Joy of Life: Vitality and health are a balance of many factors. Using a scale of 0-10 for each of the following show your level of satisfaction as it relates to you (0=no satisfaction)

Service to Others *

Career/School *

Family *

Environment: ex. shelter and climate *

Finances *

Health *

Achievement *

Health *

Fun *

Love *

And one last question: What is your commitment to making healthful changes in your diet considering it will likely entail lifestyle and dietary changes?

0=No commitment 10=Bring it on, lets get started! *

Submit

Your Forms

New Patient Intake Form

And one last question: What is your commitment to making healthful changes in your diet considering it will likely entail lifestyle and dietary changes?

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