Naturopathic Intake and Consent Forms
Dr. H Karandish NP
Today's Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
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Address
Address Line 2
City
Province
Postal Code
Phone Number
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Format: (000) 000-0000.
E-mail
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example@example.com
Occupation:
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Sex:
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Male
Female
Other
Family Doctor
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Name
Phone
Emergency Contact
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Name
Phone
Are you currently seeing any other health care providers? (i.e. Other Naturopathic Doctors, Chiropractors, Acupuncturist, Massage Therapists, etc.) If so, please list here:
Referral
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Health Information
List your health concerns (physical, emotional, or psychological) in order of importance to you, and the date your symptoms began:
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Health Concern
Date
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2
3
If you are female, are you currently pregnant?
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Yes
No
Have you had lab work done in the past year?
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Yes
No
Have you seen a Naturopathic Doctor before?
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Yes
No
If yes, please briefly describe your experience, what was it for and when:
Do you get regular screening done by another healthcare provider? (Pap test, bloodwork, etc)
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Yes
No
Do you have any dietary restrictions or preferences (religious, vegan/vegetarian, gluten-free, etc) Please specify:
Allergies and Sensitivities
List all allergies to medications, environment, and food:
Sensitivities/Intolerances? (Please list all sensitivities/intolerances to the following: food, medications, environmental, etc)
Are you regularly exposed to toxins at home or in your workplace? Please specify:
How stressful is your work or home environment, and how well do you handle these stressors?
Supplements and Medications
List all medications that you are currently taking (prescription and over the counter) and for how long (include dose):
List all supplements that you are currently taking (include brand and dose):
Medical History
List any condition that you have been diagnosed with and date of diagnosis:
Please list any serious illness, injuries, hospitalizations or surgeries that you have had and approximate dates:
Do you use any of the following? If yes, please provide details:
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What Form?
Amount per Day/Week
Alcohol
Nicotine
Caffeine
Recreational Drugs
Family History
Indicate whether any family members have had any of the following:
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Yes
Relation to You
Alcoholism
Allergies
Alzheimer's Disease
Arthritis
Asthma
Cancer (indicate type)
Depression
Diabetes
Drug Abuse
Heart Disease
High Blood Pressure
Kidney Disease
Osteoporosis
Stroke
Other Illnesses
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Is there anything else I should know before your first appointment?
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Patient Signature
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Naturopathy Consent Form
Accuracy of Information
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I certify that the above medical information is correct to my knowledge.
Privacy and Sharing of Information
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I authorize Belle Care and its associated health professionals to collect my personal and medical information as documented above. In addition, I authorize the clinic and its associated health professionals to communicate with my family doctor and/or referring doctor as deemed necessary for my beneficial treatment. I understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.
Cancellation Policy: Your appointment time is reserved just for you; a late cancellation or missed appointment has a negative impact on the practitioner’s income while taking away an opportunity for someone else to benefit from the session. As such, Belle Care requires 48-hour notice for any cancellation or change to your appointment. Clients who provide less than 48-hour notice or miss their appointment will be charged 50% of the session.
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I Agree
I Do Not Agree
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Consent: Naturopathic Assessment and Treatment
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I understand that my Naturopathic Doctor (ND) is providing services within their scope of practice as defined by the Canadian Association of Naturopathic Doctors and the College of Naturopathy of Ontario (CONO). I hereby consent that my ND may assess and treat me within the above noted parameters, and this may include, but are not limited to: recording a detailed medical history; physical examination and diagnostic testing (where required); dietary counseling; lifestyle recommendations; cupping; massage; botanical medicine; homeopathy; and physical medicine.
Consent: Naturopathic Assessment and Treatment
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I acknowledge that with any treatment there can be associated risks; those risks will be explained to me before each session and I assume those risks. I understand that it is my responsibility to ask any questions and bring up any concerns with my ND as treatment progresses. I understand that I may refuse treatment at any time or withdraw my consent without affecting my ability to receive future care.
Signature
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Should be Empty: