STEP:1
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COMPLETE OUR
PATIENT INTAKE FORM

SEE YOUR DOCTOR
BY USING SKYPE FOR
YOUR CONSULTATION!

PATIENT INTAKE FORM

Patient Privacy: Patient information will never be disclosed or sold to an individual or company. The information you provide herein is used solely by the Calgary Centre for Naturopathic Medicine for administrative, diagnostic and/or treatment purposes, and will be treated in the strictest confidence.

Please complete the entire form! The more information you can provide the doctor prior to your consultation, the better able he or she will be to help and guide you.

SECTION 1 - GENERAL INFORMATION

Name Date
Address
City Prov/State Postal/Zip Code
Phone # or Skype Name Best time to call
E-Mail Age Date of Birth

Successful health care and preventive medicine are only possible when the physician has a complete understanding of the patient physically, mentally and emotionally. The nature of your responses to the following questions will go along way in assisting our understanding of your truest desires. Your time, thoughtfulness and honesty in completing this overview will greatly aid us to assist your health needs.

Why did you choose to come to us?

What main expectation do you have regarding your telephone consultation?

What is your present level of commitment to address any underlying causes of your signs/symptoms that relate to your lifestyle?

Rate from 0 to 10, with 10 being 100% committed

What behaviours/habits do you currently engage in regularly that you believe support your health?

What behaviours / habits do you currently engage in regularly that you believe are self-destructive?

When and where did you last receive medical or health care and what was it for?

What are your most important health problems? List as many as you can in order of importance:

1.
2.
3.
4.
5.

Do you have any known contagious disease/s at this time? Yes NO

If yes, what?