Infinity Health Inc.
Dr. Alexina Mehta
#215-2211 West 4th Ave
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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
Muscle and Joint
Pain or Numbness in Shoulders
Pain or Numbness in Elbows
Pain or Numbness in Hands
Pain or Numbness in Knees
Eyes, Ears, Nose, and Throat
Do you experience PMS symptoms?
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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.)
SURGERIES and IMAGING:
Please describe your history with this.
Please describe a typical diet for you.
Sources and Amounts of:
WEIGHT and HEIGHT:
Please list any allergies to drugs or foods that you know of.
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.
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.