Name:	Date:
Date of Birth:	Sex:
Address:	Town/City:
Province:	Postal Code:
Email:
Telephone:	May we leave a message related to your visit?

Emergency Contact Information

Name:	Telephone:
Relation:

How did you hear about our clinic?: ____________________________________________________________________________

Referred by: _________________________________________________________________

Other health care providers you are seeing:

1. _____________________ 2. ____________________ 3. ____________________

_______________________ ______________________ _______________________

_______________________ ______________________ _______________________

_______________________ ______________________ _______________________

_______________________ ______________________ _______________________

Main Concern:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

How long has this condition persisted?: ______________________________________________

Previous treatments and results: ___________________________________________________

Other health concerns, in order of importance to you:

1. __________________________________________________________________________

2. __________________________________________________________________________

3. __________________________________________________________________________

4. __________________________________________________________________________

If you are female, are you currently pregnant? Yes No (please circle one)

Family History

	Who?		Who?
Allergies		Depression
Arthritis		Other mental illness
Asthma		Drug abuse/alcoholism
Heart disease		Thyroid condition
High blood pressure		Kidney Disease
Cancer		Other
Diabetes

[ ] I don't know my family medical history

Environment

Occupation _____________________________________________________________

Hobbies ________________________________________________________________

Do you exercise regularly? Y / N What do you do for exercise, how much, how often?

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

How many hours of sleep do you get a night?: ________________________________________

Do you wake up during the night? Y / N If so, what time: _______________________________

How would you describe the emotional climate of your home?:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

How stressful is your work, or other aspects of your life? How well do you handle these stresses?

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Are you exposed to significant tobacco smoke (work, home, etc.)? Y / N

Are you frequently exposed to animals (work, home, etc.)? Y / N

How is your home heated? ________________________________________________

Are you regularly exposed to toxins or other hazards (work, home, hobbies, etc.)? Please describe. __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Is there anything you feel is important that has not been covered?
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Medical History

How would you describe your general state of health? Excellent Good Fair Poor

Please indicate any serious conditions, illnesses or injuries, and any hospitalizations; along with dates. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Do you have any allergies (medicines, environmental, etc.)?
____________________________________________________________________________________________________________________________________________________________

Please list all current medications (prescription, over the counter, vitamins, herbs, homeopathics, etc.)

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Do you frequently use any of the following? (circle)

Aspirin / Laxatives / Antacids / Diet pills / Birth control pills/implants/injections

Alcohol - how much/day or week ___________________________________________________

Tobacco - form and amount/day ___________________________________________________

Caffeine - form and amount/day __________________________________________________

Recreational drugs - what and how often ____________________________________________

Do you get regular screening tests done by another doctor (blood, pap, etc.)? Y / N

Diet

Do you have any food allergies or intolerances? Please list.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Do you have any dietary restrictions (religious, vegetarian/vegan, etc.)?

____________________________________________________________________________________________________________________________________________________________

Describe a typical day's diet:
Breakfast _____________________________________________________________________

Lunch ________________________________________________________________________

Dinner _______________________________________________________________________

Snacks _______________________________________________________________________

Beverages (and total quantity) ____________________________________________________