ADULT New Patient Intake Form

ADULT New Patient Intake Form
Email*
example@example.com
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityProvince

Postal
Home Phone
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Age*

Health Information
Family Doctor Name
Family Doctor Address
Family Doctor Phone
Please enter a valid phone number.
What medications are you currently taking? (name of medication, dosage, date started and side effects) If none please enter none.*
What supplements are you currently taking? (name of supplement, how much and how often) - if none please enter none*
Are you currently under the care of a Physician(s)? (Name of Physician, Condition and Treatment(s) )
Are you currently in an exercise or diet program? Please specify.

Health History
Current Medical Complaints ~ main reasons for our appointment today. List in order of importance including possible cause and when it started.*
What major injuries or surgeries have you had, if any? (type, location and what age did it occur) - if none please enter none*

Health History - Biological Female Reproductive System

From birth onward; include any medications, surgeries, or injuries; include as much detail as possible.
What was the age of your first menses? Anything significant stand out from your early years of cycles?
Method of Birth Control? (Current and previous)
How long have you been using your current method of birth control?
Have you had any pregnancies and if so, how many? (not including miscarriages)
Have you had any miscarriages or abortions? Please include the year it occurred and which trimester.
Any complications with any of the above? Provide specifics.
Menopause?

YesNo
Start date of Menopause

MonthDayYear
Date
Lingering Complaints due to Menopause

Health History - Biological Male Endocrine Health

From birth onward; include any medications, surgeries or injuries
Any history of impotence, erectile dysfunction, prostate or urination problems? - if none please enter none.
What treatment and tests have occurred for any of the above?
Complications with any of the above?

I, the undersigned, understand that Sandra O'Grady HOM, R.BIE is a Registered Homeopath and Bioenergetic (BIE) practitioner and not a licensed medical doctor.
(Please check each of the following after reading)*

As such, I acknowledge that I am here on my own behalf and it is my right and responsibility, at any time throughout my care with Sandra O’Grady, to seek medical counsel and diagnosis, if so desired from a licensed medical doctor, for any present and/or future condition(s).I acknowledge that Sandra O’Grady does not diagnose or give direction on any current medications or diagnosis treatment plan from my licensed medical doctor.I reserve the right to terminate homeopathic and BIE treatment at any time if so inclined. I acknowledge that the state of my health is my own responsibility and that I am exercising my right to choose an alternative method of treatment, in homeopathy or BIE, that addresses my health in its entirety.I consent that after assessment, answering of questions, and discussion of homeopathic treatment options, to my satisfaction, I will voluntarily follow recommended treatment advice. I understand I can withdraw my consent at any time.I acknowledge that I understand the risks, limitations, conditions of use, and instructions for use of the select electronic communication Services such as email, text, videoconferencing (Skype, Zoom, FaceTime) and phone.I acknowledge and understand that despite recommendations that encryption software can be used as a security mechanism for electronic communications, it is possible that communications with Sandra O’Grady may not be encrypted. Despite this, I agree to communicate with the Homeopath understanding of the risk.In regards to BIE solely, I acknowledge that the GSR-120 unit is not intended to be used to diagnose, cure, prognosticate, treatment or prescribing of remedies for the treatment of disease or any act which will constitute the practice of medicine in this country in which a medical license is required.The GSR-120 unit is used to direct energy directly onto various acupuncture points on the body to help create homeostasis.Homeopathy is not covered by existing government medical insurance plans; therefore, I agree to pay all fees incurred as presented in the current rate schedule.
Please sign below advising of your consent*

Clear
Date

MonthDayYear
Please note:

All information submitted will be kept strictly confidential. Information is stored on secure servers and will not be disclosed to any 3rd party.
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ADULT New Patient Intake Form

Health Information

Health History

Health History - Biological Female Reproductive System

Health History - Biological Male Endocrine Health

Symptoms experienced in past 6-12 months:

Conditions that you have had in your lifetime:

Allergies or intolerances:

Environmental Survey

Please note: