OrléansWellness Clinic

Sharon Behrendt, N.D.

6584-A (side entrance) Richer Drive, Orleans, ON K1C 3G4

(613) 590-1343 voice facsimile 590-0582

Adult Intake

Name: ______Date: ______

Date of Birth: ______Age: ______

Address: ______Phone (office): ______

______(home): ______

______(other): ______

E-mail: ______

Occupation: ______

Referred by: ______

Other Health Care Providers:

1. 2. 3.

______

______

______

______

What are your health concerns, in order of importance to you?

  1. ______
  2. ______
  3. ______
  4. ______
  5. ______

Medical History

How would you describe your state of health?

ExcellentGoodFairPoor

Please indicate any past illnesses, injuries or hospitalizations, along with appropriate dates:

______

______

______

How many times have you been treated with antibiotics in the past 5 years? : ______

Do you frequently use any of the following? (circle)

Tylenol/AspirinLaxativesAntacidsBirth control pills/patch

Alcohol – how much? ______

Tobacco – how much? ______

Caffeine – form and amount/day: ______

Recreational drugs – what and how often: ______

Please indicate if any caused adverse reactions:

______

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

When was your last Physical Examination? ______

Have you ever had any abnormal Pap or blood work results? ______

Female History

Age of first menses: ______Age of cessation of menses: ______

Are your menses: regularirregular

Do you experience PMS symptoms? YN

What symptoms do you experience: ______

______

How often do you experience vaginal infections?

Never Rarely Frequently 

How often do you experience bladder infections?

Never RarelyFrequently 

Number of children: ______

Number of pregnancies: ______

Number of abortions/miscarriages: ______

Were there any complications associated with these? ______

Male History

How often do you experience prostate infections?

Never RarelyFrequently 

Family History

Indicate if a close relative (parent, sibling, child) has had any of the following:

Who?Who?

 Allergies/Hayfever: ______ Heart Disease: ______

 Arthritis: ______ High Blood Pressure: ______

 Asthma: ______ High Cholesterol: ______ Cancer: ______ Kidney Disease: ______ Depression/Mental illness: ______ Osteoporosis:______

 Diabetes: ______Thyroid: ______

 Drug abuse/alcoholism: ______Other: ______

 Eczema/Psoriasis ______ I don’t know my family history

Diet

Do you have any dietary restrictions (religious, vegetarian/vegan, food allergies or intolerances)? ______

Describe a typical day’s diet:

Breakfast: ______

Lunch: ______

Dinner: ______

Snacks: ______

Beverages: ______

Lifestyle and Environment

Hobbies/Recreation: ______

Do you exercise regularly? YN

What do you do for exercise, how much, how often?

______

Are you exposed to tobacco smoke at work, home, etc?YN

Are you frequently exposed to animals at work, home, etc? YN

Are you regularly exposed to toxins or other hazards (work, home, hobbies, etc)?

YN

What level of personal stress are you presently experiencing?

Minimal Average ConsiderableUnbearable 

Is the main stressor(s) (check all that apply):

Financial Work-relatedHealthFamilyRelationships 

Spiritual Other: ______

Please fill in the degree of satisfaction with each of these areas:

(0% = not at all satisfied ---100% = completely satisfied)

Family and Friends: ______Money and Financial Fitness: ______

Love and Romance: ______Environment and Earth Connection: ______

Career and Power: ______Personal Growth and Spirituality: ______

Health and Fitness: ______Fun and Recreation: ______

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

______

______

______

What long-term expectations do you have from working with me personally as your Naturopathic Physician?

______

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

(0 = no commitment --- 10 = 100% commitment)/10

What behaviors/lifestyle do you currently engage in regularly that you believe:

(a) support your health?

(b) are self destructive habits?

______

______

______

What potential obstacles do you foresee in addressing factors which are undermining your health and in adhering to prescribed therapeutic protocols?

______

Who do you know that will support you consistently with the beneficial health changes you will be making?

______

Thank you for taking the time to fill out the requested information. It will help greatly in our study of your present health and will assist us in choosing an appropriate direction to take in working towards your desired health goals.

Orleans Wellness Clinic

Sharon Behrendt, N.D.

6584-A Richer DriveOrleans, ON K1C 3G4

613 590-1343 voice facsimile 590-0582

PATIENT AGREEMENT FORM

NAME: ______

Each patient is required to read and sign this form before treatment. Your signature acknowledges the following:

  1. I understand that naturopathic medicine is not covered by OHIP, yet naturopathic expenses may be covered by private health insurance plans and may be tax deductible.
  1. The fees and services have been clarified in advance. Payment is due at the end of each visit, as the clinic does not bill insurance companies directly. Cash, interac, visa and mastercard are acceptable payment methods.

FEE SCHEDULE:

New patient – Adult (1 hour): $160.00 +GST

New patient – Child (1 hour): $130.00 +GST

60 minute follow-up – Adult: $130.00 +GST

60 minute follow-up – Child: $130.00 +GST

45 minute follow-up – Adult: $95.00 +GST

45 minute follow-up – Child: $95.00 +GST

30 minute follow-up – Adult: $65.00 +GST

30 minute follow-up – Child: $65.00 +GST

Emails will be billed according to 15-minute time periods - $20.00 + GST

  1. Twenty-four hours notice is required when canceling an appointment. Otherwise, the full visit will be charged.
  1. I am aware that appointments that run over the scheduled time will be charged the difference in 15 minute increments.

Signed: ______Date: ______

Orléans Wellness Clinic

Sharon Behrendt, N.D.

6584-A Richer Drive, Orleans, ON K1C 3G4

(613) 590-1343 voice facsimile 590-0582

Patient Consent Form

Privacy of your personal information is an important part of our Clinic, while providing you with quality naturopathic care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We will try to be as open and transparent as possible about the way we handle your personal information.

In this Clinic, Sharon Behrendt acts as the Privacy Information Officer.

All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are trained in the appropriate use and protection of your information.

Our privacy policy outlines what our Clinic is doing to ensure that:

  • Only necessary information is collected about you;
  • We only share your information with your consent;
  • Storage, retention and destruction of your personal information complies with existing legislation, and privacy protection protocols;
  • Our privacy protocols comply with privacy legislation and standards of our regulatory body, the Board of Directors of Drugless Therapy – Naturopathy.

This Clinic will collect and use information about you for the following purposes:

  • To assess your health concerns
  • To provide health care
  • To advise you of treatment options
  • To establish and maintain contact with you
  • To remind you of upcoming appointments
  • To invoice for goods and services
  • To process credit card payments
  • To collect unpaid accounts
  • To assist this Clinic to comply with all regulatory requirements

Patient Consent

I have reviewed the above information that explains how your Clinic will use my personal information, and the steps your Clinic is taking to protect my information.

I agree that Orleans Wellness Clinic can collect, use and disclose personal information about ______as set out above in the information about the Clinic’s privacy policies.

______

signatureprint name

______

datesignature of witness