Core Link Wellness Centre

Core Link Wellness Centre

518 Brant Street, Burlington, ON L7R 2G7

New Patient Intake Form

Today’s Date___________________

Name___________________________________Age_____Date of Birth___________________

Address_________________________________City__________Postal Code_______________

Telephone: (____) ____________ Work (____) ___________ Email_____________________

Marital Status: S M D W Sep No. of Children____ Names and Ages _______________

Occupation ____________________________ Employer _____________________________

Emergency Contact _______________________________ (____) ________________________

Name Telephone

MAJOR CONCERNS IN ORDER SINCE CAUSE

OF IMPORTANCE TO YOU

____________________________________ _______________ _____________________

DO YOU HAVE ANY OTHER SYMPTOMS?

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HAVE YOU HAD ANY OTHER MAJOR CONDITIONS?

WHAT HOSPITALIZATIONS, SURGERIES WHEN ? COMPLICATIONS, IF ANY

OR MAJOR INJURIES HAVE YOU HAD?

_______________________________________ ___________ _________________________ _______________________________________ ___________ _________________________ _______________________________________ ___________ _________________________

(other side) à

CURRENT MEDICATIONS AND DOSAGES

SUPPLEMENTS YOU CURRENTLY TAKE (vitamins, herbs, homeopathy)

XRAY OR SPECIAL TESTS YOU HAVE DONE

Xray, MRI, CT scan, EEG, ECG, endoscopy, colonoscopy, mammogram, ultrasound

Other ________________________________________________________________________

Adverse effects from vaccinations? _________________________________________________

Number of times antibiotics used in lifetime? _________________________________________

Recent weight gain/loss? +/- _________lbs

Exercise? ________________How often? ___________________________________________

Tobacco use? o Yes o No How often? _______________________

Alcohol use? o Yes o No How often? _______________________

Headaches? o Yes o No How often? _______________________

Allergies? o Yes o No Foods ____________________________

Drugs ____________________________

Environmental _____________________

Other ____________________________

Blood type? A B AB O

Have any family members suffered from the following?

o Alcoholism o Diabetes o Heart Disease o Paralysis

o Allergies o Epilepsy o Hay Fever o Pneumonia

o Arthritis o Eczema o High Blood Pressure o Psoriasis

o Asthma o Glaucoma o Kidney Disease o Stroke

o Cancer o Gout o Mental Illness o Syphilis

o Depression o Gonorrhea o MS o Tuberculosis

Other ________________________________________________________________________

WHAT OTHER HEALTH CARE PRACTITIONERS ARE YOU UNDER THE CARE OF?

NAME FOR WHAT CONDITION?

____________________________ _______________________________________________

Where did you learn about this clinic? ______________________________________________

Name: _________________________________ Date: __________________

Check the conditions that you are currently experiencing, or have experienced often in the past. If more space is required please use the reverse side of this sheet.

current previous current previous current previous

General Symptoms

Loss of consciousness □ □

Numbness / tingling □ □

Fever □ □

Sweats □ □

Fainting □ □

Dizziness □ □

Loss of sleep/insomnia □ □

Frequent colds / flus □ □

Loss of weight □ □

Head / Neck

Headaches □ □

Type ____________________

Vision problems □ □

TMJ concerns □ □

Earaches □ □

Decreased hearing □ □

Sinus problems □ □

Difficulty swallowing □ □

Skin

Rashes / Eczema □ □

Itching □ □

Bruise easily □ □

Dryness □ □

Boils / Hives □ □

Contagious skin disease □ □

Respiratory

Chronic cough □ □

Shortness of breath □ □

Smoking □ □

Breathing problems □ □

Asthma / Bronchitis □ □

Cardiovascular

High blood pressure □ □

Low blood pressure □ □

Bleeding disorders □ □

Chest pain □ □

Stroke □ □

Artery hardening □ □

Varicose veins □ □

Swelling of the ankles □ □

Poor circulation □ □

Angina □ □

Heart disease □ □

Genitorurinary

Trouble urinating □ □

Blood in the urine □ □

Kidney infections □ □

Bed wetting □ □

Prostate trouble □ □

Gastrointestional

Poor digestion □ □

Indigestion □ □

Excessive hunger □ □

Belching or gas □ □

Nausea / Vomiting □ □

Abdominal pain □ □

Constipation □ □

Diarrhea □ □

Hemorrhoids □ □

Liver concerns □ □

Gall bladder trouble □ □

Bladder concerns □ □

Ulcer □ □

Diabetes □ □

Infections / Illnesses

Herpes □ □

Hepatitis □ □

Plantar warts □ □

TB □ □

HIV / AIDs □ □

Cancer □ □

Allergies □ □

Muscles and Joints

Stiff neck □ □

Backache □ □

Swollen joints □ □

Painful tail bone □ □

Foot trouble L / R □ □

Shoulder pain L / R □ □

Elbow pain L / R □ □

Wrist pain L / R □ □

Hip pain L / R □ □

Knee pain L / R □ □

Arthritis □ □

Weakness / loss strength □ □

Women’s Health

Painful menstruation □ □

Excessive flow □ □

Irregular cycle □ □

Hot flushes □ □

Cramps or backache □ □

Vaginal discharge □ □

Swollen breasts □ □

Lumps in the breast □ □

Are you pregnant Yes □ No □

On birth control Yes □ No □

# of pregnancies _______

# of children _________

Please list anything not covered above: __________________________________________________________________________________________________________________________________________________________________________Do you exercise? Yes □ No Do you smoke? Yes □ No □

Do you consume alcohol or recreational drugs? If so, please list _________________________________

CORE LINK WELLNESS CENTRE

INFORMED CONSENT TO NATUROPATHIC THERAPEUTIC PROCEDURES

Name__________________________________________________

Address______________________________________________

City and Postal Code__________________________________

Attending N.D._______________________________________

RECOMMENDED THERAPEUTIC PROCEDURE(S) / PLAN

(Including those by referral to another practitioner)

(Filled in at visit) ________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________

I, the undersigned, do hereby acknowledge that I have been informed of and understand the recommended therapeutic procedure(s)/ plan and have discussed to my satisfaction this and any requests for related information with the naturopathic doctor named above and/or with his/her office or clinical assistant(s). I further acknowledge and confirm that I have been informed of and understand the therapeutic procedure(s)/plan with respect to the financial costs, expected benefits, potential nsks and side effects the likely consequences of not having/following the procedure(s)/plan, and what alternative course(s) of action are available to me.

As a result I do hereby voluntarily consent/ withhold/ my informed consent for the recommended therapeutic procedure(s)/plan as specified above. I also understand that I may change the status of my voluntary consent at any time.

Signature_______________________ Print Name___________________________ Date __________________________Witness Signature______________________

PATIENT CONSENT FOR COLLECTION, USE AND DISCLOSURE OF

PERSONAL INFORMATION

Privacy of your personal information is an important part of our clinic while providing you with quality naturopathic care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We will try to be as open and transparent as possible about the way we handle your personal information.

In this clinic, Payam Kiani, ND acts as the Privacy Information Officer.

All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are trained in the appropriate use and protection of your information.

Our privacy policy outlines what our Clinic is doing to ensure that:

Only necessary information is collected about you;

We only share your information with your consent;

Storage, retention and destruction of your personal information complies with existing legislation

and privacy protection protocols;

Our privacy protocols comply with privacy legislation and standards or our regulatory body, the

Board of Directors of Drugless Therapy — Naturopathy.

How our clinic collects, uses and discloses patients’ personal information

Our clinic understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined here how our clinic is using and disclosing your information.

This clinic will collect, use and disclose information about you for the following purposes:

To assess your health concerns

To provide health care

To advise you of treatment options

To establish and maintain contact with you

To send you newsletters and other information mailings

To remind you of upcoming appointments

To communicate with other treating health-care providers

To allow us to efficiently follow-up for treatment, care and billing

To complete claims for insurance purposes

To comply with legal and regulatory requirements of our regulatory body, the Board of Directors

of Drugless Therapy — Naturopathy acting under the authority of the Drugless Practitioners Act

To invoice for goods and services~

To process credit card payments

To collect unpaid accounts

To assist this clinic to comply with all regulatory requirements

To comply generally with the law

To allow potential purchasers, practice brokers or advisors to conduct an audit in preparation for

a practice sale

By signing the consent section of this Patient Consent Form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal information as outlined above.

Patient Consent ~

I have reviewed the above information that explains how your clinic will use my personal information, and the steps your clinic is taking to protect my information.

I agree that the Core Link Wellness can collect, use and disclose my personal information as set out above in the information about the clinic’s privacy policies.

Signature_______________________ Print Name___________________________ Date __________________________ Witness Signature______________________