PREVENTATIVE HEALTH LIFESTYLE ASSESSMENT: ARE YOU LIVING AN OPTIMAL LIFESTYLE?


Prevention and health education is at the core of what we do at the North York Lifestyle Medicine Clinic. We want to empower our community (including you!) with the right knowledge and skills to prevent disease in the first place.

This is why we offer our Preventative Health Lifestyle Assessment service.

No symptoms does not necessarily mean no disease risk; many chronic diseases like diabetes, osteoporosis, heart disease, and cancer can develop silently for years without presenting any obvious symptoms. Through our Preventative Health Lifestyle Assessment, we help you to ascertain whether your current lifestyle is one that puts you at risk for disease. We present scientific advice to help give you the best chance at living an optimal life.

Below is the assessment form. Please complete the form to the best of your knowledge. Honesty is very important! (We are not here to judge but rather to gather the information we need to best advise you). Thank you in advance for taking the time to complete this form as it is very comprehensive in nature. 

Your assessment form will be reviewed by the doctor and you will receive a follow-up email to book an appointment.

* Important: This assessment is for individuals who may or may not have a medical condition. Even if you feel healthy, you can take this assessment to uncover any potential disease risk and how you can optimize your lifestyle. 


Preventative Health Lifestyle Assessment

Name *
Name
Address *
Address
Phone
Phone
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?
Medial Concerns
Please list past medical conditions and hospitalizations
Please list medical conditions in the family including: siblings, parents, and grandparents.
Blood tests and Labs *
In the past year, which tests have been performed? Please indicate all that apply.
For women between ages 21 to 69 yrs of age.
For adults over age 50 and/or postmenopausal women
For women 45 years and over.
For adults 50+ years of age
Dental check-up in past year? *
Please list all allergies past and present
Please include dosages if possible, and when you started taking.
Review of Systems
Symptoms
Please check any of the below that you have noticed recently
Please select usual appearance
Usual appearance of urine
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 = I can't be more stressed than I am now
Have you currently or recently had suicidal thoughts?
1 = no stress 10 = I can't be more stressed than I am now
Occupation
Sexual health
Spirituality
My spiritual practices are