Integrated Health Intake Form (FULL)

Integrated Health Intake Form (FULL)
Please fill in all of the information below with as much detail as you can and to the best of your ability so that you may recieve the best care possible! When you get to the bottom of each page, click NEXT until you reach the end. You will be asked to sign before you can submit. Thank you!

** Allow about 30 to 45 minutes to complete the entire form.
** Make sure to finish in one sitting, and SUBMIT at the end, or your info may be lost.
** Please visit this page to make sure you have completed all the steps necessary before your first visit with us!

* This information will be kept strictly confidential as per the Health Professions Act, Personal Information Protection Act, the regulations of each of the professional governing bodies for the professionals practicing at Empower Health Clinic and Canadian law. Your personal information is collected for the purpose of providing health care and for administrative purposes. It will not be disclosed for other purposes without your consent other than for reasons stated in the laws.

To provide you with the best possible care, professionals practicing out of Empower Health Clinic share an Electronic Medical Record (EMR) system. All Practitioners and staff are bound by a Privacy & Confidentiality Agreement to protect your privacy. Practitioners must also fully comply with the privacy regulations of their professional colleges and designations and the privacy regulations of British Columbia and Canada.
ABOUT YOU
Full Name*

First NameMiddle NameLast Name
Email (to send you a confirmation for submitting this form!)
example@example.com
Phone Number*

Area CodePhone Number
Age
Birthday

MonthDayYear
I identify my gender as…*

MaleFemaleTransOther
Marital Status

SingleCommon-LawMarriedOther
Number of Children
Your Occupation:
Number of hours I work per week:
Appointments
Missed Appointments

Empower Health requires at least 24 hours notice if you wish to cancel or re-schedule an appointment or you will be charged for the time set aside and, in the case of a scheduled treatment, the cost of non-reusable products prepared for you. Notice of cancellation or rescheduling must be given during regular clinic hours or prior to regular clinic hours covering this 24 hour period.

MY HEALTH STORY
Section 1 - Current Health Status
I am under the care of another primary care provider? (MD, ND, Specialist?)

YesNo
Primary Care Provider's name:

PrefixFirst NameLast NameSuffix
Provider's Number
Names and designations of all other primary care providers I see are: (include GP/MD, Specialists or NDs:
I am also under the care of a:

ChiropractorMassage TherapistTCM Doctor/AcupuncturistPhysiotherapistCounsellor/PsychiatristOther

My Main Health Concerns
Today my MAIN reason for this visit is (Problem #1):
Please list one concern that is the most important to be addressed in your first visit
My concern started:
My concern has been

ImprovingWorseningStaying the same
The triggers of my concern are:
My life is affected by my concern in these ways:
These are the things that I have done to try and resolve my concern: (i.e. therapies, medications, supplements, diet or lifestyle changes, etc.)
My desired outcome after treatment is:
Another CURRENT health concern is (Problem #2):
Significant past health concerns will be discussed in Section 2 when you tell us about your Medical History
My concern started:
My concern has been

ImprovingWorseningStaying the same
The triggers of my concern are:
My life is affected by my concern in these ways:
These are the things that I have done to try and resolve my concern: (i.e. therapies, medications, supplements, diet or lifestyle changes, etc.)
My desired outcome after treatment is:
Another CURRENT health concern is (Problem #3):
Significant past health concerns will be discussed in Section 2 when you tell us about your Medical History
My concern started:
My concern has been

ImprovingWorseningStaying the same
The triggers of my concern are:
My life is affected by my concern in these ways:
These are the things that I have done to try and resolve my concern: (i.e. therapies, medications, supplements, diet or lifestyle changes, etc.)
My desired outcome after treatment is:
Additionally I would like to tell you:

Labs, Diagnostics, Imaging
I have had recent and/or significant LABS, IMAGING or DIAGNOSTICS done:

Lab WorkImaging (X-Ray, MRI, CT Scan)MammographyBone Density ScanCardiovascular Assessment (ECG, Stress Test, Angiography)EEGPhysical ExamProstate or Gynaecological/PAP ExamOther
For those checked above, these are the relevant or abnormal RESULTS and findings:
Include dates of results
****Please upload any available labs or reports if you have them in PDF form, or you can email them to betternow@empowerhealth.ca

Upload Files
If unable to upload or email, please bring your results to your first visit Cancelof

Allergies & Infections
These are all my allergies & things I react to: (i.e intolerances/sensitivities to food, environment and drugs)
I have an infectious or contagious disease or condition (eg. HIV, Hep A/B/C, Cold/Flu)

YesNoNot Sure
The infectious disease or contagious condition is:

Medications and Supplements

These are my current prescription medications:

	Prescription Medication name	Dose (ex: 5mg)	Frequency (ex: once per day)	Date started	Reason for taking
1
2
3
4
5
6
7
8

These are all the over-the-counter (OTC) medications I take: (pain killers, antacids, cough/cold, etc.)

	OTC Medication name	Dose (ex: 5mg)	Frequency (ex: once per day)	Date started	Reason for taking
1
2
3
4
5
6
7
8

These are all of the SUPPLEMENTS, HERBS & "SUPERFOODS" that I use regularly:

	Supplement name	Brand	Dose (ex: 5mg)	Frequency (ex: once per day)	Date started	Reason for taking
1
2
3
4
5
6
7
8

These are my current prescription medications:
Include name, exact dose & frequency, date started and reason taking
These are all the over-the-counter medications I take: (pain killers, antacids, cough/cold, etc.)
Include brand, dose, frequency & reason
These are all of the SUPPLEMENTS, HERBS & "SUPERFOODS" that I use regularly:
Include brand, dose, frequency & reason taking

	# of...
Pregnancies
Miscarrigaes
Live births
Abortions
C-sections
Living children

Section 6 - My Integrated Health Goals
I envision my relationship with Empower health...
I also think you should know......about me, so I can receive the best care possible.
Please call me to set up my first appointment (INSERT PHONE HERE IF YES):

Area CodePhone Number
My signature below affirms that I have answered the above as truthfully and completely as possible:
Today's Date*

YearMonthDay
Signature
Should be Empty:

	Time(s) (am/pm)	Foods	Drinks
Breakfast
Lunch
Dinner
Snacks

	# of servings per day	# of servings per week
Wheat/Gluten
Dairy
Sugar, Candy
Refined or white flour foods, baked goods, desserts
Fried food
Fast food

	# of glasses per day	# per week	# per month
Water/herbal tea
Juice
Coffee
Tea
Pop/Soda
Wine/beer/spirits

	Past	Current
Joint degeneration, arthritis or stiffness
Joint sprain or dislocation
Osteoporosis/Osteopenia
Fracture
Spine or Disc Issues (Herniation or injury)
Head injuries/Concussion
Back, body aches or recurring muscle strain
Low back or knee pain not associated with injury
Pain under the lower rib cage
Movement or balance problems

Integrated Health Intake Form (FULL)

ABOUT YOU

Appointments

MY HEALTH STORY

Section 1 - Current Health Status

My Main Health Concerns

Labs, Diagnostics, Imaging

Allergies & Infections

Medications and Supplements

Section 2 - My Health History

Medical History

Family Health History

Section 3 - My General Health

Diet, Eating Habits & Digestive Health

Toxic Exposures & Detoxification Assessment

Sleep, Energy & Activity

Stress, Trauma & Mental Health

Physical Pain & Body Sensations

Heading

Section 4 - Hormones and Immune System

Female Hormonal Health

Male Hormonal Health

Immune System Function

Section 5 - Other Risk Factors

Head

Section 6 - My Integrated Health Goals

My signature below affirms that I have answered the above as truthfully and completely as possible:

	Medical condition or diagnosis	Date diagnosed
1
2
3
4
5

	Surgery, hospitalization or injury	Date this occured
1
2
3
4
5