Adult Intake Form

Please take a moment to fill out our online intake form before your visit. All information is kept completely confidential.

First name

Last name

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Date of birth

Day

Month

Year

Gender

Emergency Contact (Relationship)

Emergency Contact Phone

How did you hear about us?

What are your HEALTH CONCERNS/GOALS? List in order of priority.

List all CURRENT prescribed medications. (Name/Dosage/Length taken)

List all CURRENT vitamins, minerals, herbs that you take more than occasionally. (Name/Dose/Length taken)

List any prescribed medication you've had an ADVERSE REACTION to in the past. (Name/When taken/Reaction)

How many times have you been treated with ANTIBIOTICS in the past 5 years?

Have you lived in a moldy home or been exposed to mold at your workplace?

BLOOD TYPE

Date of last PHYSICAL EXAM (For what reason?)

Do you get regular SCREENING TESTS done? (Pap, breast, pelvic, blood test, etc)

Yes

If you SMOKE, please write Type/Amount Per Day/Years Smoked/Year Stopped.

If you do RECREATIONAL DRUGS please write Type/Frequency.

What is your OCCUPATION and WORK HOURS?

STRESS LEVEL

Minimal

Average

Considerable

Unbearable

What do you do to deal with stress?

What are your hobbies?

Do you exercise regularly? (Type/Frequency)

CHRONOLOGICAL HEALTH HISTORY helps to establish trends in a person's health that may be relevant to present conditions. Indicate below any accidents, broken bones, illnesses, surgeries, and any emotional traumas such as deaths, loss of jobs, divorces, etc

Age 1-5:

Age 6-10:

Age 11-15:

Age 16-20:

Age 21-25:

Age 26-30:

Age 31-35:

Age 36-40:

Age 41-45:

Age 46-50:

Age at which periods first started?

Which hormonal contraceptive have you been on? For how long?

What is your CURRENT method of contraception?

Are you currently trying to conceive?

Yes

Are you currently breastfeeding?

Yes

I certify that the above medical information is correct to my knowledge.

PRIVACY AND SHARING OF INFORMATION: I authorize Dr. Ji Woon Min to collect my personal and medical information as documented above. In addition, I authorize Dr. Ji Woon Min to communicate with my family doctor and/or referring doctor as deemed necessary for my beneficial treatment. I also 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 visit leaves a hole in the schedule that could have been filled by another patient. As such, we require 24 hours notice for any cancellations or changes to your appointment. Patients who provide less than 24 hours notice, or miss their appointment, will be charged the full consultation fee.

NATUROPATHIC MEDICINE INFORMED CONSENT

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. My ND will take a thorough case history and perform a relevant physical examination. It is very important that I inform my naturopathic doctor of any medical concerns or medication and supplements I may be taking. I will advise my ND if I am pregnant, suspect I am pregnant or if I am breastfeeding.

As a patient I will receive information about my diagnosis and/or treatment, alternative courses of action, the material effects, costs, expected benefits, risks, side effects and in each case the consequences of not having the diagnosis and/or treatment acted upon. As with any form of medical intervention there can be health risks associated with treatment by naturopathic medicine. Possible side effects of naturopathic medical care include:

Aggravation of pre-existing symptoms
Allergic reactions to supplements or herbs

I understand that my naturopathic doctor cannot prescribe over text, whatsapp or email without having a consultation to go over pertinent information such as my signs, symptoms and lab results to fully understand my situation to prescribe a customized treatment plan just for me.

I understand that the results are not guaranteed. I do not expect the naturopathic doctors to be able to anticipate and explain all risks and complications. With this knowledge, I voluntarily consent to Naturopathic care I intend this consent form to cover the entire course of treatment. I understand that I am free to withdraw my consent at any time.

I UNDERSTAND AND GIVE CONSENT.

Adult Intake Form

Dr. Ji Woon Min, Naturopathic Doctor