Registration Form - Blue Health

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

Consistent with our firm commitment to practice whole-person, individualized care, we would like to get to know you better.  Below is our initial intake form for all new patients. The information you provide will help us understand you as a whole person and adequately address your health concerns.


1. Please complete the form below to the best of your knowledge.

2. After submitting the form, you will be prompted to book an appointment online here.

Thank you in advance for taking time to complete this form as it is very comprehensive in nature. 

Name *
Which session are you attending? *
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 *
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 *
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 list any other symptoms or health concerns not listed above that you have currently experienced whether they seem related or not to your present chief health concern(s).
Please select usual appearance
Usual appearance of urine
Do you get colds, runny noses, and flus easily?
Do you get frequent headaches
How long is your typical 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
My spiritual practices are
Best method of contact
Please indicate any other comments you feel are necessary for us when considering your case