Naturopathic Intake Form

Dr. Ayesha Qureshi, BSc (Hons), N.D.
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Last Name
Date of Birth

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Age
Gender
Marital Status
Address
Home number
Emergency contact and number
Cell phone number
What is your preferred method of contact?

Email.Cell phone.Home phone.
Email
example@example.com
Family Doctor
Family Doctor fax number
How did you hear about our clinic?
Other healthcare providers you are seeking?
PERSONAL INFORMATION AND MEDICAL HISTORY

What is your main health concern you are seeking acupuncture for?

What are your other health concerns in order of importance?
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2.
3.
What are your main Goals for Treatment:
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2.
3.
How would you describe your general state of health: (please check)

PoorFairGoodExcellent
Allergies (food, drugs and environmental)
Please list current medications and dosages
Please list current natural health products, supplements, herbs and homeopathic remedies
Please list any lab work, X ray, MRI/CT scans, ultrasound or other studies you have had in the last year
Of the following, which immunizations have you had (check all that apply)

DPT (Diptheria, pertussis, tetanus)Haemophilus influenzae BMMR (measles, mumps, rubella)Chicken poxHepatitis AHepatits BFlu shotPolioOther
Please circle any areas of pain.
HEALTH HABITS

Exercise. How often:
HEALTH HABITS

Smoking. How many cigarettes per day:
Smoking. How many cigarettes per day:
Alcohol. How many drinks per day

Recreational drugs. Type and frequency of use:Dietary restrictions:
Alcohol. How many drinks per day
Recreational drugs. Type and frequency of use:
Past surgeries and hospitalizations
FAMILY HEALTH HISTORY
Please indicate if there is family history of the following conditions: (Check all that apply)

DiabetesHeart diseaseHypertensionHepatitisSeizuresAsthmaEczemaPsoriasisCancerKidney diseaseLiver diseaseThyroid diseaseDepressionOther (please specify)
TheClinic understands the importance of protecting your personal information. Below is an outline of how our office is using and disclosing of your information.

The office will collect, use and disclose only necessary information about you for the following purposes To collect information for assessments conducted by our practitioners To collect fees for services and dispensary purchases Seminars, workshops and surveys to promote patient education (optional) You information will be disclosed to the following individuals All healthcare practitioners employed at The Clinic To any emergency service personnel dispatched If one's life is endangered We will only share your information with your consent. Storage, retention and destruction of your personal information complies with existing legislation and privacy protocols set out by College of Naturopaths of Ontario (CONO) and Ontario's Personal Health Information Protection Act
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Naturopathic medicine is the treatment and prevention of diseases by natural means. Naturopathic Doctors 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. Your visit may consist of a thorough case history and a screening physical examination. Treatments recommended include botanical medicine, Traditional Chinese Medicine and acupuncture, homeopathy, clinical nutrition, hydrotherapy and physical therapy such as spinal adjustments, exercises and massage.

It is important that I am informed of any diseases that you are suffering from and if you are on any medication or over the counter drugs, supplements or herbal products. If you are pregnant, become pregnant or are breast-feeding, please let your doctor know immediately.

The health risks associated with naturopathic medical treatment may include but are not limited to: aggravation of pre- existing symptoms; allergic reactions to supplements or herbs; pain, bruising or injury from acupuncture; fainting or puncturing of an organ with acupuncture needles. Results are not guaranteed and not all risks and complications can be anticipated and explained.
Naturopathic medical care is not covered under OHIP but may be covered by your extended health insurance. Please check with your plan. Direct billing is available at the clinic for most insurance companies.

The clinic does not guarantee treatment results and naturopathic therapies may take time to improve my condition. That my Naturopathic Doctor, Dr. Ayesha Qureshi BSc (Hons), ND. will explain to me the exact nature of any treatment provided, the risks of treatment, alternatives to undergoing treatment and the risks of not undergoing treatment and will answer any questions I may have to the best of her ability. Any treatment or advice provided to me by Dr. Ayesha Qureshi BSc (Hons), ND. is not mutually exclusive from any treatment or advice that I may be receiving now or in the future from another licensed health care provider. Iam at liberty to seek or continue medical care from a physician or surgeon or other health care provider qualified to practice in Ontario. No employee, agent, or anyone else under the clinic's direction or control is suggesting or recommending to me to refrain from seeking or following the advice of another licensed health care provider. That I am responsible for the fees incurred during care and treatments. That I am free to withdraw my consent and to discontinue treatment at any time.

By signing the intake form, you are agreeing to the above terms and consent to treatment by Dr. Ayesha QureshiBSc (Hons),

I intend this consent to apply to all present and future naturopathic care.
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Signature of Naturopathic Doctor

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FAMILY HEALTH HISTORY