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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:
                       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.
    Health History:
    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.
    Family History:  Please List  ages, any major health problems, and if deceased, what they died from and at what age.
    Social History
    Health Habits
    Diet
    Sleep
    Home Environment and Other Environmental Exposures
    Female Reproductive Health (Skip to the next section if you are male)
    Male Reproductive Health
    Medical History
    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)

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