Health History Form (General) Page 4
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5Family Naturopathic Clinic Adult Intake and Consent Form
Do you have a religious or spiritual practice and what is it? _______________________________________________________________
Do you have dietary restrictions, religious or ethical? ____________________________________________________________________
Do you meditate? ________________ Do you enjoy your work? YES
NO
Do you take vacations? YES
NO
What is your level of education? ___________________________ Are you happy with this? ____________________________________
Female Reproduction:
Age of first period _________________ Age at menopause ___________________ Length of cycles______________________________
Length of bleeds___________________ Are they: heavy
medium
light
clotted
dark
light color
Do you have spotting or bleeding between periods and since when?_________________________________________________________
Do you have PMS? ____(circle all that apply) bloating, breast tenderness, irritability, depression, headaches, mood swings, food cravings
Number of pregnancies ________ Number of abortions ________ Number of live births________ Number of miscarriages _________
Have you had difficulty conceiving? (Please describe) ___________________________________________________________________
Date and results of last PAP smear ______________________ Mammogram __________________Self breast exam_________________
Have you ever had an abnormal pap/mammogram? YES
NO
If yes, when? __________________________________________
Are you sexually active? YES
NO
If you use birth control, what kind? _____________________________________________
Have you ever been or are now physically or sexually abused? ____________________________________________________________
Male Reproduction:
Any problems with impotency? YES
NO
Any sores on your penis? YES
NO
Any discharge? YES
NO
Any problems urinating? YES
NO
Any known prostate problems? ( if so describe)_____________________________________
Date of last prostate examination_______________________ Date of last self testicular examination _____________________________
Are you sexually active? YES
NO
If you use birth control, what kind?_______________________________________________
Have you ever been or are now physically or sexually abused? ____________________________________________________________
Your Work and Home Environment:
How long have you lived at your present address?_________________ Where have you lived previously?__________________________
Is your home damp or moldy? YES
NO
How is your home heated?_________________________________________________
Can you open windows where you work? YES
NO
Is their air filtration systems at work? YES
NO
Does your work expose you to toxic chemicals and fumes? YES
NO
Describe______________________
Do any of your hobbies expose you to toxic chemicals? YES
NO
Are you exposed to second hand smoke? YES
NO
Thank you for taking the time to fill out this form.
Please return this form to your Doctor:
Dr. Kristin Schnurr, ND
Family Naturopathic Clinic
Suite #101-391 Tyee Rd, Victoria, B.C., V8W 2J9
Tel: (250) 475 1522 / fax: (250) 590-1502
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