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Adult Patient Intake Form

Infinity Health Inc.
Dr. Alexina Mehta
Naturopathic Physician
#215-2211 West 4th Ave
Vancouver, BC
V6K 4S2

The information in this form is kept in strict confidence and will be transmitted securely and directly to Dr. Mehta on 10/16/2021
Name:
Name:
First
Last
Address:
Address:
Street Address
Address Line 2
City
State/Province
Zip/Postal
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Context of Care

Please list your health concerns in order of priority:

Please list any medications and supplements that you are currently taking, along with doses and the reason you are taking them:


Review of Systems:

Please check any of the following that you have or have had previously.

O = Occasional
F = Frequent
C = Constant

General

Allergy
Chills
Convulsions
Dizziness
Fainting
Fatigue
Fever
Headache
Loss of Sleep
Loss of Weight
Depression
Nervousness
Neuralgia
Numbness
Sweats
Tremors

Muscle and Joint

Arthritis
Bursitis
Foot Trouble
Hernia
Lower Back Pain
Lumbago
Neck Pain or Stiffness
Pain Between Shoulders
Pain or Numbness in Shoulders
Pain or Numbness in Elbows
Pain or Numbness in Hands
Pain or Numbness in Hips
Pain or Numbness in Legs
Pain or Numbness in Knees
Pain or Numbness in Feet
Painful Tail Bone
Poor Posture
Sciatica
Spinal Curvature
Swollen Joints

Gastrointestinal

Belching or Gas
Colitis
Colon Trouble
Constipation
Diarrhea
Difficult Digestion
Abdominal Distension
Excessive Hunger
Gall Bladder Trouble
Hemorrhoids
Intestinal Worms
Jaundice
Liver Trouble
Nausea
Stomach Pain
Poor Appetite
Vomiting
Vomiting of Blood

Eyes, Ears, Nose, and Throat

Asthma
Cold
Dental Decay
Earache
Ear Discharge
Ear Noises
Enlarged Glands
Enlarged Thyroid
Eye Pain
Failing Vision
Far Sightedness
Gum Trouble
Hay Fever
Hoarseness
Nasal Obstruction
Near Sightedness
Nosebleeds
Sinus Infection
Sore Throat
Tonsillitis

Cardiovascular

Hardening of Arteries
High Blood Pressure
Low Blood Pressure
Pain Over Heart
Poor Circulation
Rapid Heart Beat
Slow Heart Beat
Swelling of Ankles

Respiratory

Chest Pain
Chronic Cough
Difficulty Breathing
Spitting Up Blood
Spitting Up Phlegm
Wheezing

Skin

Boils
Bruise Easily
Dryness
Hives or Allergy
Itching
Skin Eruptions (Rash)
Varicose Veins

Genito-Urinary

Bedwetting
Blood in Urine
Frequent Urination
Poor Kidney Control
Kidney Infection
Kidney Stones
Painful Urination
Prostrate Trouble
Pus in Urine

Women

Congested Breasts
Cramps / Backache
Excess Menstrual Flow
Hot Flashes
Irregular Cycle
Lumps in Breasts
Menopause
Painful Menstruation
Vaginal Discharge

Females:

days.

Bleeding is
Do you experience PMS symptoms?
Please choose whether you are

Males:

PLEASE DESCRIBE YOUR FAMILY'S HEALTH:

(be sure to include current age or age of death, major illness history, including diabetes, heart disease, osteoporosis, cancer, allergies, etc.)

Mother
Father
Siblings
Siblings
Siblings
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather

SURGERIES and IMAGING:

Please describe your history with this.

DIET:

Please describe a typical diet for you.

Sources and Amounts of:

WEIGHT and HEIGHT:

Weight in Pounds
Height in Feet and Inches

ALLERGIES:

Please list any allergies to drugs or foods that you know of.

LIFESTYLE:

What are your primary sources of stress?

CURRENT HEALTH STATUS:

Thank you for filling out this form. We look forward to working with you towards higher levels of health.


CONSENT FORM

Dear Patients:
Naturopathic examination includes: physical and clinical diagnosis, traditional Chinese medical diagnosis, energetic testing and lab work. Therapeutic procedures may include: homeopathy, spinal adjustment, botanical medicine, acupuncture, manual muscle therapy, craniosacral therapy, bowen therapy, clinical nutritional, lifestyle counselling, biofeedback and mind-body awareness.

Occasionally, complications may arise. Any procedure intended to help may have complications. While the chances of experiencing complications are minimal, it is the practice of this clinic to inform our patients about them. These complications may include, but are not limited to: soreness, inflammation, soft tissue injury, dizziness, burns, bruising, stroke, and temporary worsening of symptoms. More serious complications are extremely rare.

I have read and understand the above statements regarding potential treatment side effects. I also understand that there is no guarantee or warranty for a specific cure result.

I am aware that 24 hours notice must be given for all cancelled appointments or the full fee for the visit is due. I understand that I am responsible for payment at the time services are rendered. Dispensary items and lab tests must be paid for in full before leaving the office.

Please click this checkmark to indicate that you have read, understand, and agree to this consent form. Checking this box implies parental consent for applicants under the age of 19, for whom parental consent is required for naturopathic treatment.