Registration Form - Blue Health


Thank you for choosing the Blue Health Program. We look forward to partnering together on a journey to wholeness.

The information provided will go to the Blue Health program medical doctor and naturopathic doctor in advance of the initial medical screening day.


Name *
Name
Which session are you attending? *
Host Site member?
Are you a member of the host site church?
Fee *
I understand that the initial program down payment needs to be made in order to secure a spot in the program. (Invoice will be sent via email or mail) Blue Health North York = $110 Blue Health Peterborough = $99
Pre and post medical screening *
I understand that all participants must undergo pre and post medical screening with the staff medical doctor and naturopathic doctor. They will explain the program, do physical measurements such as blood pressure, weight, height, etc, render any treatments if necessary, and requisition for pre and post program lab work.
Sex *
Address *
Address
Phone number
Phone number
Students are eligible for a 40% discount on consultations
Are you currently enrolled in any of the following social assistance programs? *
Those enrolled in government social assistance programs are eligible for discounted rates.
Emergency Contact
Name *
Name
Phone *
Phone
Medical Concern
Medical condition(s) *
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. Example(s): - Eating more bran to address sluggish bowels - garlic for cholesterol - exercising to lose weight
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
List all medications and supplements (if not listed above). Please include dosages if possible, and when you started taking.
Review of Systems
Please select usual appearance
Usual appearance of urine
Do you get colds, runny noses, and flus easily?
Do you get frequent headaches
Menstruation (If applicable)
How long is your cycle?
Description of menstrual flow (color, volume, etc)
Are your cycles regular?
Diet & Nutrition
Diet category *
Physical Activity & Exercise
How many days a week are you doing structured physical activity?
Please share with us what types of exercise activities you are currently engaged in
Sleep & Sunlight
When do you typically go to bed and when do you usually wake up?
Mood & Emotions
Worry *
Over the last 2 weeks, have you experienced any of the following symptoms?
Mood *
Over the last 2 weeks, have you experienced any of the following problems?
1 = no stress 10 = Extremely high stress
1 = no energy 10 = Highest level of energy
Occupation
Spirituality
My spiritual practices are
Miscellaneous
Best method of contact
Please indicate any other comments you feel are necessary for us when considering your case