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Dr. Ashley Kowalski, HBSc., Naturopathic Doctor (ND)
Stella’s Touch Health Spa & Clinic
140 Craig St., Russell ON, K4R 1A1
T: (613) 482-0879 -
New Patient Instructions and Appointments:
Welcome. This form is a little lengthy but it's purpose is to help us get the best use of our time together.
Naturopathic medicine is the treatment and prevention of diseases by natural means. A naturopathic intake assesses the whole person, taking into consideration physical, mental/emotional and spiritual aspects of the individual. A number of different approaches are used: diet and nutritional supplements, botanical medicine, homeopathy, hydrotherapy, acupuncture, and lifestyle counseling.
What to bring to your initial visit: All lab/blood work that has been done within the last year and any supplements that you are currently taking.
Appointment questions: I will gladly re-schedule or re-book your appointments, please provide me with 24-hours notice.
Please be organized: Please arrive 10 minutes before every appointment. If you are late, understand that you may not get the full allotted time for your appointment. I understand that sometimes situations arise beyond your control i.e. snow storms, freezing rain, emergencies, etc. and in those circumstances; every effort will be made to accommodate you. Please bring with you all the necessary paperwork to hand in.
Cancellations: Should be made at least 24 hrs in advance (but earlier would be appreciated). A 24-hour cancellation policy is in effect for all appointments. You can either call the office, or email. To avoid a full visit charge, please notify the office 24-hours before all scheduled appointments. This is to ensure fairness to both the physician and patients. This allows us to notify patients that may be on a waiting list.
Email: While email is a convenient way to communicate with the office, please be aware that responding to emails does take time and expertise. Any emails can be directed to . I try to accommodate questions regarding treatment clarification at no charge. However, email responses are prioritized for emergencies. Contact me if you have a reasonable quick/simple question about a supplement, diagnostic test, or a therapy reaction. Anything the doctor deems in depth will require another appointment. Any discussion of new treatment options or symptoms requires you to schedule a follow up consultation. All doctors are bound by patient confidentiality and privacy laws and unable to provide any information that requires access to your patient chart over email. If you have any questions or concerns that have not been addressed, please book in a scheduled consultation.
I look forward to meeting you!J
Dr. Ashley Kowalski, HBSc., Naturopathic Doctor (ND)
Stella’s Touch Health Spa & Clinic
140 Craig St., Russell ON, K4R 1A1
T: (613) 482-0879 -
Please print and complete the following Intake Form and bring it to your first appointment. Alternatively, you can save the form to your computer and email the completed form to in advance of your first appointment.
Adult Naturopathic Patient Intake Form:
Last Name: / First Name: / Middle Name:Date of Birth:
(DD/MM/YYYY) / Age: / Sex:
F / M (circle one) / Occupation:
Contact Information
Full Address (including unit/apartment number): / City, Province:
Postal Code: / Daytime phone number: / Evening phone number: / May we leave messages regarding your visit?
Y / N (circle one)
Email:
Emergency Contact Information
1) Last Name: / First Name: / Relationship:
Daytime Phone Number: / Evening Phone Number:
2) Last Name: / First Name: / Relationship:
Daytime Phone Number: / Evening Phone Number:
Other Healthcare Providers
1) Name:
Specialty/Focus:
Phone Number: / 2) Name:
Specialty/Focus:
Phone Number: / 3) Name:
Specialty/Focus:
Phone Number:
Date of last medical doctor visit: / Date of last physical exam:
Please list regular screening tests performed by other physicians:
How did you hear about this clinic? Why did you choose to come to this clinic?
If referred, please state by whom:
What do you know about our approach?
Have you been treated by a Naturopathic Doctor before? Y / N (circle one)
If yes, by whom? / Date of last visit to ND:
Health Assessment Questionnaire:
In your opinion, what are your most important health concerns? List in order of importance.1.
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How do your conditions/ailments affect you?
What do you think is happening and why?
Medical History
If you are female, are you pregnant?
Y / N (circle one) / Are you trying to become pregnant?
Y / N (circle one)
Height: / Current Weight: / Past Min. Weight: / Past Max. Weight:
Vaccination/ Immunization Record: Please circle all that apply
Please note vaccinations in bold are considered routine as per the Ontario Childhood Immunization Schedule 2004:
DPT (Diptheria, Pertussis, Tetanus) BCG (Tuberculosis) Pneumococcal conjugate
MMR (Measles, Mumps, Rubella) Hepatitis A (Meningitis/Pneumonia)
Gardasil/Cervarix Hepatitis B Meningococcal C conjugate
Haemophilus Influenza B Polio (Meningitis)
Flu vaccine Varivax/Varilrix (Chicken Pox)
Other:
Did any of the vaccines cause adverse reactions, if yes please indicate:
Which of the following childhood illnesses have you had? Please circle all that apply
Asthma Polio Mumps
Rheumatic Fever Scarlet fever Measles
Rubella (German Measles) Whooping cough Roseola
Chicken Pox
List any previously diagnosed medical conditions:
1. / Treatment received: / Year:
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List all allergies (medications, food, supplements, environmental, etc.)
1. / Reaction Type:
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List all prescription drugs (including oral contraceptive, etc.), over-the-counter medications (pain killers, antacid, etc.), herbs and natural supplements (vitamins, homeopathics, etc.), that you are taking
Medication / Dosage / Start Date
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Please check the meds you currently take: (also indicate how often, or long, each is taken for)
Tylenol-¨ Tums-¨ Aspirin-¨ Anti-acids -¨ Laxatives-¨ Diet pills-¨
Birth control pills- Implants- Injections- Advil-
Family Medical HistoryInclude: heart disease, high blood pressure, cancer, diabetes, depression, and other mental illness, drug and alcohol abuse, kidney disease, arthritis, infertility, headaches, neurological conditions, hyper/hypothyroid or other relevant information
Age / Health History / Age / Health History
Father / Mother
Grandmother (Paternal) / Grandmother (Maternal)
Grandfather
(Paternal) / Grandfather (Maternal)
Siblings / Children
Review of Systems
Please circle if you have experienced any of the following symptoms, and indicate if they are current (C=Current) or from the past (P=Past):
General:
Night sweats Weight gain Sweat easily
Weight loss Fatigue Chills
Fevers Bleed or bruise easily Unusual tastes or smells
Excessive thirst Anemia Heat or cold intolerance
Poor appetite Poor sleep Frequent cold/flu
Skin and Hair:
Rashes Change in moles Change in skin color/texture
Itching Ulcers Loss of hair
Eczema Acne Dandruff
Head/ Eyes/ Ears/ Nose/ Throat (HEENT):
Headaches/Migraines Night blindness Sinus problems
Neck masses Glaucoma Nose bleeds
Hay fever Cataracts Jaw clicks or pain
Eye pain/ strain Earaches Tooth pain
Frequent colds/flu Poor hearing Hoarseness
Blurry vision Ringing in ears Recurrent sore throat
Using glasses Facial pain Mouth sores
Snoring
Heart and Circulation:
High blood pressure Fainting Cold hands or feet
Low blood pressure Chest pain Swelling of hands or feet
Irregular heartbeat Heart palpitations Deep leg pain
Blood clots Varicose veins Dizziness
Respiration:
Difficulty breathing Asthma Coughing up blood
Cough Wheezing Pneumonia
Bronchitis Production of phlegm
Digestion:
Indigestion/ heartburn Abdominal pain or cramps Rectal pain
Gas or bloating Nausea Hemorrhoids
Bad breath Vomiting Blood or mucus in stool
Constipation Chronic laxative use Diarrhea
Poor appetite Change in appetite Excessive hunger
Genitourinary:
Frequent urination Unable to hold urine Kidney stones
Urgency to urinate Decrease in flow Sores on genitals
Pain on urination Distinctive/ odd color Impotence
Waking to urinate Blood in urine
Musculoskeletal:
Neck pain Knee pain Broken bones
Back pain Foot/ ankle pain Muscle weakness
Hand / wrist pain Hip pain Muscle spasms or cramps
Shoulder pains Joint pain or stiffness Sciatica
Nervous System/Psychological:
Loss of balance Depression Difficulty concentrating
Quick temper/ irritability Susceptible to stress Seizures
Poor memory Dizziness Areas of numbness or tingling
Anxiety Lack of coordination Mood swings
Eating disorder Addiction Paralysis
Female Reproductive: (circle only those that apply when more than one option exists, if applicable)
Irregular periods Nipple discharge Pain during intercourse
Vaginal discharge Breast lumps Birth control
Heavy flow Breast tenderness Gonorrhea/Chlamydia/Syphilis
Clots Pregnant Herpes/Genital warts
Period cramps Sexually active Yeast infections
Age of first menses: __
Duration of period: __
Days between cycle: __
Date of start of last period: __
Date of last PAP smear: __
Any abnormal PAPS? __
Any pre-menstrual symptoms? If so, describe ______
Do you perform monthly self-breast exams? __
Do you use birth control? If so, what type and for how long? ______
Are you currently pregnant? __
Number of pregnancies: ___ # of births: __ # of Miscarriages: __ # of Abortions: __
Male Reproductive: (circle only those that apply when more than one option exists, if applicable)
Penile discharge Testicular masses Sexually active
Penile sores Impotence Herpes/Genital warts
Hernias Premature ejaculations Gonorrhea/Chlamydia/Syphilis
Testicular pain Prostate disease Yeast infections
General
Smoker? __ How many packs/day? __ Years smoked: ____
Alcohol use? __ Type and amount of alcohol/day: ______
Recreational drug use? ___ Type and amount/day: ______
Do you exercise regularly? Type and amount/day: ______
Do you sleep well? Refreshed in the morning? __ # of hours/night: ___
Additional Questions/Information
What three expectations do you have of working with our clinic?
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What long-term expectations do you have from working with our clinic?
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What expectations do you have of me personally as your physician?
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What behaviors or lifestyle habits do you currently engage in regularly that you believe support your health? Please list below:
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What behaviors or lifestyle habits do you currently engage in regularly that you believe are self-destructive lifestyle habits? Please list below:
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What potential obstacles do you foresee in addressing the lifestyle factors which are undermining your health and in adhering to the therapeutic protocols which I will be sharing with you?
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Who do you know that will sincerely support you consistently with the beneficial lifestyle changes you will be making?
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What do you LOVE to do? J
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Is there any other important information that you would like me to know?
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Thank you!
*A message to all patients:
If you are experiencing a wait-time that is slightly longer than anticipated, I do apologize. I am finishing up with another patient and I will be with you shortly because YOUR health and time matters. J
DECLARATION AND CONSENT TO TREAT
This is to acknowledge that I (or parent/legal guardian) have been informed and understand that:
Naturopathic medicine is the treatment and prevention of diseases by natural means. A naturopathic intake assesses the whole person, taking into consideration physical, mental/emotional and spiritual aspects of the individual. A number of different approaches are used: Diet and nutritional supplements, botanical medicine, homeopathy, hydrotherapy, acupuncture, and lifestyle counseling.
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:
· aggravation of pre-existing symptoms
· allergic reaction to supplements or herbs
· Pain, fainting, bruising, or injury from venipuncture or acupuncture
I agree to pay my full account at the time of each visit or treatment, including fee for services and cost of supplements and remedies.
I understand that a 24-hour cancellation policy is in effect for all appointments. To avoid a visit charge, I will notify the office 24-hours before all scheduled appointments. If a cancellation is received in less than 24 hours, there will be a charge for the FULL follow-up visit fee, which will be billed automatically to my credit card on file.
I have read and understood the cancellation policy: ______(Signature)
Privacy of your personal information is an important part of my practice. I understand the importance of protecting your personal information and your records will be kept confidential.
This consent form is intended to cover the entire course of treatments in this office. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time.
Date: ______
Patient’s printed name: ______
Patient’s signature: ______
Parent’s/legal guardian signature (if under 18 years): ______