Personal Information Name: Date of First Visit: MSP # Address: City, Province: Postal code: Telephone # (home): Telephone # (work):
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1 Dr. Sara Kinnon Bellevue Natural Health Clinic 1467 Bellevue Avenue West Vancouver, BC V7T 1C3 Personal Information Name: Date of First Visit: MSP # Address: City, Province: Postal code: Telephone # (home): Telephone # (work): address: Occupation: Birthday: Age: Are you: Single Partnership Married Separated Divorced Widowed Live with: Alone Partner Parents Friends Children Relatives Emergency Contact Name: Relationship: Phone #: How did you hear about Drs Kinnon/Weisenburger? Do you currently have an active ICBC or WCB claim? Are you on Premium Assistance (MSP)? List your current health care providers (includes medical doctors, chiropractors, counselors, massage, physiotherapist, acupuncturist) Name Profession Do you have any known contagious diseases at this time? No Yes, what? Correspondence (your will never be sold, shared or traded) Would you like to receive a copy of my newsletter via ? No Yes Consent I hereby consent to naturopathic treatment from Dr Kinnon. I understand this consent is voluntary and may be revoked at any time. I accept responsibility for prompt payment for therapies provided. Signed: Date: 1
2 Health Overview Comprehensive health care requires a complete picture of your health. Please take the time to complete this questionnaire carefully. If you are unsure about a question, mark it and we can discuss it during the visit. What are your most important health problems? importance to you List as many as you can, in order of Family History - I don t know my family history (skip to next section) Age, if living Age at death Cause of death Check all that apply: Glaucoma High blood pressure Asthma HIV/AIDS Tuberculosis Cancer (list type) Diabetes Epilepsy Stroke Heart disease Allergies Thyroid problems Osteoporosis Other (please list) Mother Father Sibling(s) Grandparent Children Spouse Childhood illnesses (Check all that apply) Chicken pox Mumps Measles Rubella Whooping cough Diphteria Scarlet fever Asthma Others: Immunization history (Check all that apply) Tetanus Measles/mumps/rubella Pertussis Diptheria Hepatitis A Hepatitis B Polio Flu shot Others: List known allergies or sensitivies: Foods: Medications: Environmental factors: Chemicals: 2
3 Do you currently take or use: Laxatives Pain relievers Antacids Cortisone Sleeping pills Antibiotics Anti-depressants Hormones Birth control pills/patch/shot List all current medications with dosages: Prescription medications: Over the counter medications: Supplements: Natural remedies (herbal, homeopathic): What accidents/traumas have you had? What hospitalizations or surgeries have you had? What medical tests (x-rays, CT scans, MRI, ECG) have you had? General Information Current height : What time of day is your energy best? Current weight: Worst? Review of Systems: Check all continuing or recurrent problems General Weight loss Weight gain Fatigue Sleep disturbance Endocrine Thyroid problem Heat or cold intolerance Hypoglycemia Diabetes Excessive thirst Excessive hunger Fatigue Seasonal depression Mental / Emotional Depression Mood Swings Anxiety or nervousness Considered/Attempted suicide Tension Poor concentration Memory problems Immune Reactions to vaccinations Chronic Fatigue Syndrome Chronic infections Chronically swollen glands Slow wound healing Neurologic Seizures/epilepsy Paralysis Muscle weakness Numbness or tingling Loss of memory Easily stressed Vertigo or dizziness Loss of balance 3
4 Skin Rashes Eczema, Hives Acne Boils Itching Color Change Hair Loss Lumps Dry or scaling Night Sweats Excessive or no sweat Mouth and Throat Frequent sore throat Copious saliva Teeth grinding Mouth ulcers Sore tongue/lips Gum problems Hoarseness Loss of voice Dental cavities Jaw clicks Cold sores Head Ears Headaches Head Injury Migraines Jaw/TMJ problems Fainting Hearing loss Ringing Earaches Dizziness Sensitivity to noise Discharge from ears Nose and Sinuses Frequent colds Nose Bleeds Stuffiness Hayfever Sinus problems Loss of smell Eyes Glasses or contacts Color blind Double Vision Spots in eyes Recent change in vision Blurred vision Eye pain/strain Sensitive to light Eyes water excessively Bloodshot or puffy eyes Dryness Neck Lumps Swollen glands Goiter Pain or stiffness Cardiovascular Heart disease High/Low Blood Pressure Murmurs Blood clots Fainting Phlebitis Palpitations/Fluttering Rheumatic Fever Chest pain Swelling in ankles Respiratory Cough Sputum (mucus) Spitting up blood Wheezing Painful breathing Emphysema Difficulty breathing Pain on breathing Shortness of breath Shortness of breath lying down Gastrointestinal Bowel Movements: How often? Is this a change? Constipation Diarrhea Trouble swallowing 4
5 Heartburn Change in thirst Change in appetite Abdominal pain or cramps Belching or passing gas Nausea/vomiting Hemorrhoids Black stools Blood or mucus stool Undigested food in stool Ulcer Jaundice (yellow skin) Urinary Pain on urination Increased frequency Frequency at night Inability to hold urine Blood in urine Difficulty starting to urinate Frequent infections Kidney stones Musculoskeletal Joint pain or stiffness Broken bones Muscle weakness Muscle spasms or cramps Sciatica Mark areas you currently feel pain: Blood / Peripheral Vascular Easy bleeding or bruising Anemia Deep leg pain Cold hands/feet Varicose veins Thrombophlebitis Fluid retention Male Reproduction Hernias Testicular masses Testicular pain Do you do testicular self-exam? Prostate problems Venereal disease Discharge or sores Are you sexually active? No Yes Birth control? No Yes, type: Erectile dysfunction Low libido Premature ejaculation Sexually transmitted infection Female Reproduction / Breasts Do you do breast self-exams? Recent changes in breasts Breast lumps Breast pain/tenderness Nipple discharge Date of last annual exam/pap Any abnormal PAPs? No Yes, when: Age of first menses? Are you sexually active? Low libido Pain during intercourse Sexually transmitted infection Fill in this section if pre-menopausal: Irregular or no cycle: Duration of menses: days Length of cycle: days Bleeding between cycles Abnormal bleeding Painful menses Clotting Heavy or excessive flow Discharge PMS Birth control? No Yes, type: Difficulty conceiving Perimenopausal Fill this section if menopausal: Age of last menses Any menopausal symptoms? Vaginal bleeding since menopause 5
6 Lifestyle How often do you eat out? How often do you consume: Coffee Pop Sugar Added salt Alcohol Recreational drugs Tobacco Artificial sweeteners What are your main interests and hobbies? What exercise do you do and how often? How many hours sleep do you get? Do you awake feeling rested? Do you have supportive relationships? Do you have any occupational hazards? Have you ever been treated for an addiction? Smoked previously? How many years? How many packs per day? Do you have a religious or spiritual practice? Is there anything else you would like to add or comment on? Context of Care Why did you choose to come to this clinic? What long term expectations do you have? What expectations do you have of me as your naturopathic physician? What is your current level of commitment to addressing your health issues? I am willing to make any changes and do whatever in necessary I am willing to make some changes in my lifestyle to feel better I may consider change if absolutely necessary to feel better I am specifically looking for a medication/surgical alternative I am here to learn more about my healthcare options and what you offer Thank you for taking the time to fill in this information. 6
7 7
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