paediatric intake form - vortala · preferred method of contact: email / phone mother’s name: ......

7-2016 Tenth Line Rd.Orléans, ON K4A 4X4

(613) 837-9777www.findfreedom.ca

Paediatric Intake Form

Patient Information: Today’s Date: ________________________

Name:___________________________ Sex:__________________ Date of Birth:_________________________

Age:____________ Home Address:_______________________________ City:__________________________

Province:________________________ Postal Code:____________________Grade in School:______________

Primary Contact Information:

Name:_________________________________________ Relationship:_________________________________

Phone# Home:_______________________ Work:_______________________ Cell:______________________

Email:_________________________________________________________________

Can we email you invoices, treatment plans, and appointment reminders? Y / N

Preferred method of contact: Email / Phone

Mother’s Name:________________________________ Occupation:___________________________________

Father’s Name:_________________________________ Occupation:___________________________________

Parents are (circle): Married Separated Divorced Living Together

Other: ______________________________________________________________________________________

Do you have insurance? Yes / No

Name of Patient’s Family Doctor and phone number:______________________________________________

Other Physicians seen and their specialty:________________________________________________________

How did you hear about me?___________________________________________________________________

__________________________________ ___________________________________ ____________________Patient’s Signature Parent or Guardian’s Signature Date

Dr. Rachel Bell, ND 2016 Tenth Line, Unit 7, Orléans, ON K4A 4X4 (613) 837-9777 [email protected]

Chief Concerns:Reason for Office Visit (List in order of importance):1. ___________________________________________________________________________________________ 2. ___________________________________________________________________________________________3. ___________________________________________________________________________________________

Please list diagnosis and treatments your child has had:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please list all surgeries and hospitalizations including the date occurred:1.___________________________________________ 2. _____________________________________________3.___________________________________________ 4. _____________________________________________

Any known allergies to foods, drugs, animals or the environment? _____________________________________________________________________________________________

Medical History:Hearing test normal: Y / N Vision test normal: Y / NLearning Impediments: Y / No / Not Tested / PastSpeech Impediments: Y / No / Not Tested / Past

Please mark any of the conditions your child currently has with a C, or has had in the past with a P

Child’s Health HistoryWas the child breastfed? Y / N How long: ____________________________________________Was formula used? Y / N Which formula: ______________________ During what ages: ______________When did child walk: ____________________ Talk: _____________________ Develop Teeth: _____________When was child put on solid food?_____________________________________________________


C P Ear Infections C P Chronic Sniffles C P RubellaC P Colds C P Hyperactivity C P PertussisC P Strep throat C P Growing Pains C P InfluenzaC P Jaundice C P Colic C P Chicken PoxC P Cradle cap C P Anemia C P MeaslesC P Eczema or Psoriasis C P Warts C P RoseolaC P Diarrhea C P Nightmares C P MumpsC P Constipation C P Bed-wetting C P Scarlet feverC P Picky eater C P Tantrums C P MonoC P Poor teeth C P Fear/Phobias C P MeningitisC P Diaper rash C P Pneumonia C P ScabiesC P Stomach ache C P Styes C P Molluscum contagiosumC P Early puberty C P Bladder infectionsC P Impetigo C P WormsC P Ingrown toenails C P Tonsillitis


Vaccination History:For the following vaccinations mark: Y= yes has had them N= no has not had them S= has had some

Has your child had any adverse reaction to vaccinations? Y / N If so, explain______________________________________________________________

Family History:Please list health history of family members including conditions such as cancer (including type), diabetes, celiac, stroke, mental illness, arthritis, asthma, learning disability, allergies, eczema etc.

Mother’s Pregnancy History:Please answer Y = Yes or N = No to the following questions about mother’s health during pregnancy

Birth History:Term Length: Full ________________ Premature ____________wks. Late ________________wks.Length of Labour __________________________________ Weight at birth ____________________________Complications _______________________________________________________________________________The birth (circle all that apply): Vaginal C-section Induced Forceps Anaesthesia used

Environment:Is the child in (circle): School Daycare Homecare Other_____________________________Does anyone in the child’s household smoke? Y / N Do you know of any toxins or other hazards the child is regularly exposed to?_____________________________________________________________________________________________________________________What is the emotional climate of the child’s home?_____________________________________________________________________________________________________________________________________________Is there anything you feel has not been covered?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Y N S Diphtheria Y N S Tetanus Y N S PertussisY N S Polio Y N S Hib Y N S PneumococcalY N S Meningococcal Y N S Measles Y N S MumpsY N S Rubella Y N S Varicella (chicken pox) Y N S Hep BY N S Influenza Y N S Other:

Family Member Age if Alive Age at Death Conditions MotherMaternal GrandmotherMaternal GrandfatherFatherPaternal GrandmotherPaternal GrandfatherSiblings

Y N Nausea / Vomiting Y N Vaginal Birth Y N Recreational DrugsY N Smoking Y N Emotional Stress Y N Gestational DiabetesY N Coffee Y N Preeclampsia Y N Hypertension



CONSENT TO TREAT

Naturopathic medicine is the treatment and prevention of diseases by natural means. Naturopaths assess the whole person, taking into consideration physical, mental, emotional and spiritual aspects of the individual. Gentle, non-invasive techniques are generally used in order to stimulate the body’s inherent healing capacity.

At your first appointment you can expect a thorough medical history and physical examination. Any relevant lab work that is necessary will be ordered or referred for at this time. Because some therapies must be used with caution when dealing with particular conditions (such as pregnancy and lactation, kidney disease, and heart disease), it is very important that you inform your naturopathic doctor imme-diately of any disease that you are suffering from, as well as any forms of medication, drugs, or supple-ments you are taking.

There are some slight health risks to treatment by naturopathic medicine. These include but are not limited to: • Aggravation of pre-existing symptoms • Allergic reactions to supplements or herbs • Pain, bruising or injury from venipuncture or acupuncture • Fainting or puncturing of an organ with acupuncture needles

I understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others unless so directed by myself unless law requires it. I understand that I may look at my medical record at anytime and can request a copy of it by paying the appropriate fee.

I understand that the results are not guaranteed. I do not expect the Naturopathic Doctor to be able to anticipate and explain all risks and complications.

I intend this consent form to cover the entire course of treatment for my present condition. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time.

Patient Name: (Please Print) ___________________________________________

Signature of Patient (or Guardian): ____________________________________

Date: ___________________________________________

Naturopathic Doctor: _____________________________________________ Dr Rachel Bell, ND. #2943




PRIVACY POLICY FORM

Privacy of your personal information is an important part of your experience with Rachel Bell, Naturopathic Doctor (ND). I understand the importance of protecting your personal information while providing you with high quality naturopathic care. I am committed to collecting, using and disclosing your personal information responsibly.

To demonstrate this commitment to you, please find below an outline of how the office is using and disclosing your information: • Only necessary information is collected about you • I only share your information with your consent • Storage, retention and destruction of your personal information complies with existing legislation and privacy protection protocols. • My privacy protocols comply with privacy legislation and standards of our regulatory body, the College of Naturopaths of Ontario.

HOW MY CLINIC USES, COLLECTS AND DISCLOSES PERSONAL INFORMATION • 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 invoice for goods and services • To process credit card payments • To collect unpaid accounts • To comply with all regulatory and legal requirements including court orders, statutory requirements to advise authorities of child abuse, reportable diseases and individuals who may be an imminent threat to harm themselves or others

By signing this patient consent form you have given your consent to collection, use and/or disclosure of your personal information as outlined above.

I have reviewed the above information that explains how Rachel Bell, ND will use my personal information and the steps that she is taking to protect my information. I agree that Rachel Bell, ND can collect, use and disclose personal information about me or my child as set out in the above privacy policy.

____________________________________ ______________________________ _____________________Signature Print Name Date


paediatric intake form - vortala · preferred method of contact: email / phone mother’s name: ......

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