COMPASSION HEALTH COMPREHENSIVE INITIAL INTAKE FORM FOR NEW PATIENTS

Thank you for choosing Pathways to Wholeness Lifestyle Medicine Centre. We look forward to partnering together on a journey to wholeness.

* Important: This form is only for individuals who are not presently a patient at Pathways to Wholeness Lifestyle Medicine Centre. If you are already a patient and need to book an appointment, click here.

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.

Steps:

1. Please complete the form below to the best of your knowledge. Honesty is very important as we are not here to judge but rather to explore the best approach to take in your care.

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 *
Name
Sex *
Phone number
Phone number
Address *
Address
Emergency Contact
Name *
Name
Phone *
Phone
Other Providers
List other health care providers you currently work with (name and profession will suffice).
Insurance coverage *
Does your extended health care plan cover naturopathic medicine?
Service Delivery
We treat patients using the following primary modalities: lifestyle medicine (nutrition, exercise, sleep, etc), botanical medicine, hydrotherapy, and clinical nutrition/supplements. We do not practice acupuncture based on the philosophy of traditional Chinese medicine, nor do we utilize homeopathy.
Sevice delivery method *
Initial consult will be held at the Compassion Health expo, however, all subsequent consults will be held at clinic: 4150 Chesswood Drive, North York, ON, M3J2B9
Interns *
Naturopathic medical school senior interns may be involved in the initial intake. All patient care will be supervised by our staff Naturopathic Doctor.
If you need translation, please let us know what your primary language is?
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
Menstruation
How long is your typical cycle?
Description of menstrual flow (color, volume, etc)
Are your cycles regular?
Diet & Nutrition
Diet category *
My typical times for breakfast, lunch, and dinner are? Include snack times
Types of oil I use *
Click all that applies
I use oil for *
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
Please list any activities you would like to explore and also activities you absolutely dislike doing.
Equipment available at home are
Click all that apply
How do you travel to and from work? *
List if any
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
Have you currently or recently had suicidal thoughts?
1 = no energy 10 = Highest level of energy
Occupation
Sexual health
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