Group Code (if applicable)
Are you a student currently enrolled in a post-secondary institution in Ontario?
Students are eligible for a 40% discount on consultations
Health Concern and History
Please write a history of the chief concern(s) including: when it started, current symptoms and treatments (including medications, supplements), what you hope to achieve through naturopathic care, and any other pertinent information you feel is necessary.
Please list any particular treatments you are currently doing to address your health concern.
- Eating more bran to address sluggish bowels
- garlic for cholesterol
- exercising to lose weight
Personal medical history
Please list past medical conditions and hospitalizations
Please list medical conditions in the family including: siblings, parents, and grandparents.
Please list all allergies past and present
Smoking and Recreational drugs
Quit within the past year
Quit more than a year ago
Medications and supplements
List all medications and supplements (if not listed above). Please include dosages if possible, and when you started taking.
1 - 2 times/d
3 - 4 times/d
Every other day
Only a few times a day
Usual appearance of urine
Estimated weight in pounds
Menstruation (If applicable)
Menstrual cycle length
How long is your cycle?
Description of flow
Description of menstrual flow (color, volume, etc)
Are your cycles regular?
I drink alcohol
A few times a week
Only social occasions
Physical Activity & Exercise
Frequency of physical activity
How many days a week are you doing structured physical activity?
Current physical activities
Please share with us what types of exercise activities you are currently engaged in
Direct sunlight each day?
I'm out in the sun often
Typical hours of sleep each night
I feel well rested after sleeping
Bed time and wake time
When do you typically go to bed and when do you usually wake up?
Time to fall asleep
Up to 15 mins
Up to 30 mins
Up to an hour
Beyond 2 hours
Wake up in the middle of the night?
Yes to use bathroom
Yes for no particular reason
Yes due to nightmares
Rate your stress out of 10
1 = no stress
10 = Extremely high stress
Rate your energy level out of 10
1 = no energy
10 = Highest level of energy
My connection with my family is
I am a spiritual person
I am part of a spiritual community
Would you like to be added to our emailing list for clinic updates, promotions, and health information?
How did you hear about the Blue Health
Referral from healthcare provider
Health benefits/Insurance company
Please indicate any other comments you feel are necessary for us when considering your case
Thank you for registering for Blue Health. A few important details to take note of:
1. We will be in touch shortly to schedule a time slot for your pre-program medical screening. 2. A lab requisition will be mailed to your home. Please go to the lab and run the tests as soon as possible. The lab test results will be reviewed by the program medical doctor / naturopathic doctor during the screening session. You must be fasted prior to the lab. 3. If you have any further questions, please do not hesitate to email: email@example.com Thank you for choosing us as partners on your health journey.
Your partners in Health, Pathways to Wholeness Lifestyle Medicine Center 647-853-3455 firstname.lastname@example.org www.pathwaystowholeness.ca