Dr. Kate Hunter, ND Vita Health Clinic
1560 Yonge Street

Toronto, Ontario

M4T 2S9

Name ______
Date ______

Date of birth ______(M/D/Y)
Gender ______

Address:______

E-mail Address:______

Telephone number: Home:______Work:______Cell:______

May we leave messages relating to your visits? Y / N Which Phone Number______

Emergency contact: Name: ______

Phone number: (______)______Relation:______

How did you hear about Dr. Hunter? Please check one of the following:

Referral

Advertising

Website

Social Media (Facebook, Twitter etc.)

Information Session

Other health care providers you are seeing:

Name:______Specialty:______

Ph (______)______Date of last visit: ______

Name:______Specialty:______

Ph (______)______Date of last visit: ______

Have you ever consulted a Naturopathic Doctor, an Acupuncturist, a Nutritionist or Counselor before? (Please circle)

Health Goals

Please list most important health concerns and goals in their order of significance:

1. ______

2.______

3.______

4.______

5.______

If you are female are you currently pregnant? Yes No (Please circle one)

Due date______

Medical history

How would you describe your general state of health? (Please circle one)

Excellent Good Fair Poor

Please indicate any serious conditions, illnesses or injuries, and any hospitalizations; along with approximate dates.

1) ______Date: ______

2) ______Date: ______

3) ______Date: ______

4) ______Date: ______
5) ______Date: ______

6) ______Date: ______

Do you have any allergies/sensitivities (medicines, environmental, etc.)?

1) ______4) ______

2) ______5) ______

3) ______

Please list all current medications/natural health products (prescription, over-the-counter, vitamins, herbs, homeopathics, etc.) and the date started:

1) ______Date started: ______

2) ______Date started: ______
3) ______Date started: ______

4) ______Date started: ______
5) ______Date started: ______

6) ______Date started: ______

Please list past prescription medications/natural health products:

1) ______Date: ______

2) ______Date: ______

3) ______Date: ______

4) ______Date: ______

5) ______Date: ______

6) ______Date: ______

Please circle Yes (Y), No (N) or Past (P) regarding use of the following:

Aspirin,Tylenol, Advil or other pain relievers Y N P
Reactine, Benedryl, or other antihistamines Y N P
Laxatives Y N P
Antacids Y N P

Diet pills Y N P
Birth control Y N P Type (please circle) Pills / Implants / Injections

Antibiotics Y N P

Approximate number of prescriptions: ______

Alcohol—how much/day or week ______

Tobacco—form and amount/day ______

Caffeine—form and amount/day ______

Recreational drugs—what and how often______

Please circle which immunizations you have had:

DPT (diphtheria, pertussis, tetanus) Haemophilus influenza B Hepatitis A

Tetanus booster; when? ______

“Flu” Hepatitis B MMR (measles, mumps, rubella) Polio Smallpox

Other ______

Please indicate if any caused adverse reactions: ______

Do you get regular screening tests done by another doctor? (Pap, blood tests, etc.)? Y / N

Last time you had blood work done______

Personal and Family History

CONDITION / FAMILY MEMBER / AGE at DIAGNOSIS / OUTCOME
Alcoholism/ drug abuse
High Blood Pressure
Heart Disease
Anemia
Cancer; type?
Arthritis
Asthma
Allergies
Diabetes
Eczema
Epilepsy
Depression
Anxiety
Osteoporosis
Headaches/Migraines
Kidney disease
Gallbladder disease
Liver disease

I don’t know my family medical history Y / N

Diet

Do you have any food allergies or intolerances? Please list.

1) ______

2) ______

3) ______

4) ______

5) ______

6) ______

Do you have any dietary restrictions (religious, vegetarian/vegan, etc.)?

Environment

Occupation ______

Hobbies ______

Do you exercise regularly? Y / N What do you do for exercise, how much, how often?

______

Are you exposed to significant tobacco smoke (work, home, etc.)? Y / N

Are you frequently exposed to animals (work, pets, etc.)? Y / N

Are you regularly or have you ever been regularly exposed to solvents, heavy metals, fumes, pesticides/herbicides or other toxic materials (work, home, hobbies, etc.)? Please describe:

______

Describe your stress levels: ______

Is there anything that you feel is important that has not been covered?

______

For file use only