Toronto Naturopathic Doctor: Wellness Programs: Alternative Medicine: Homeopathy

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Complications:

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Dr. Anca's Protocol for immune support-kids
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Dr. Anca's Protocol for weight loss
Only $8.00

Dr. Anca's cold and flu Prevention Protocol=Homeopathic "flu-shot"
Only $10.00

Early detection-Glucose Test
Only $14.99

Dr. Anca's Protocol for Depression
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Please note: Our ability to draw effective conclusion about your present state of health and the best way to improve it depends, to certain extents, on your ability to complete this questionnaire honestly and accurately. The doctor is the only person who will review this survey and your confidentiality is strictly maintained. If you have questions or concerns about this questionnaire, please call the office at once and we will help you to decide how to best solve the issue.

Please be sensitive to the fact that some people are not able to tolerate the odor of the cigarettes, perfume cologne or after-shave lotions. Please come to our office smoke and fragrance free. We will appreciate your attention to this. Thank you.

In order to make your consultation more efficient, please fill out the Intake Form ahead of time and Send it (if your consultation is Online) or Print it (if your consultation is in the office) and bring it with you at the time of your appointment.

CHILD INTAKE FORM

Personal Information

Patient's Name:

Mother's Name:

Address:

Postal Code:

Home Phone:

Business Phone:

Date of Birth:
mm/dd/yyyy

Age:

Sex:

Weight: (pounds)

How did you find out about our office?

Name of your family doctor

Addres of Dr.'s Office/Hospital where your child's records are kept?

Parent's Email:

................................................................................................................................

Please state your primary reason for attending this office. If this involves a specific condition, please describe it in detail. In your own words, list the very first time that you noticed this condition and describe carefully any factors that you suspect may have plaued a role in its onset and perpetuation.

Please list every detail and give the doctor the opportunity to distinguish what may not be relevant to your case.

Do you have any other reason to visit this office other than the one described above?

MEDICAL HISTORY

Check the box that applies to your health history

Chicken Pox	Scarlet Fever	Tonsilitis
Measles	Pneumonia	Ear Infection

Mumps	Frequent Colds	Rheumatic Fever
Rubela	Allergies

Other:

CHILD TESTS HISTORY

Electroencephalogram:

When?

Where?

Results?

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Physiological Evaluation:

When?

Where?

Results?

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Hearing:

When?

Where?

Results?

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Speech/Language:

When?

Where?

Results?

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Injuries/Surgeries/Hospitalizations/Accidents (Please List)

IMMUNIZATION

Check the box that appies to your health history

Measles	Polio	Tetanus
Small Pox	DPT	MMR
Diphtheria	Mumps	Influenza
Hepatitis

Others:

MEDICATIONS

Aspirin:

Now:

Past:

Antibiotics:

Now:

Past:

Anti-histamine:

Now:

Past:

Decongestant:

Now:

Past:

Ibuprofen:

Now:

Past:

Tylenol:

Now:

Past:

Allergies to Drugs Supplements:

Now:

Past:

Please list your allergie(s) sources

FAMILY HISTORY

Heart Disease	Diabetes	Birth Deffects
Goiter	Hypertension	Arthritis
Tuberculosis	Kidney Disease	Cancer
Allergies	Mental Illness	Stomach Disease

Previous pregnancies by mother, miscarriages, complications?

Any significant medical problems with the other children?

SYMPTOMS

Type "C" for Current if you are currently experiencing the symptom or "P" for Past if you had the symptom in the past.

Hives	Bed Wetting	Cries easily
Eczema	Burning Urination	Nervous
Acne	Bloody Urine	Sleep Problem
Chronic Rash	Stomach aches	Nightmares
Hair Loss	Constipation	Unusual fears
Excessive Fatigue	Diarrhea	Night Sweats
Sore Throats	Gas	Sensitive to Light
Frequent Colds	Frequent Vomiting	Body/Breath Odour
Canker Sores	Change in Appetite	Motion/Car Sickness
High Fevers	No Appetite	Nose Bleeds
Easy Brusing	Vomiting Spells	Joint Pains
Dizzy Spells	Bleeding Gums	Flat Feet
Anemia	Bleeding Tendency	Hearing Loss
Cough	Jaundice	Heart Murmur
Wheezing	Frequent Headaches

PARENT INFORMATION

Mother's Age at Child's Birth:

Father's Age at Child's Birth:

Father General Health Status:

Mother's Health During Pregnancy (Check if any)

Bleeding	Illness	Diabetes
Cigarettes, Alcohol, drugs	Nausea	Medications
Hypertension	Thyroid Problems	Physical or Emotional
		trauma

BIRTH HISTORY

Has your child had any of the following problems?

	Jaundice	Diarrhea	Birth Defects
	Rashes	Colic	Fever
	Cerebral Palsy	Allergies	"Blue Baby"
	Seizures	Birth Injuries
		Explain:
	Food Intolerance/Allergies (If Any)
	Breast Fed? How long? Formula? What Kind?
	Age began solid foods:
	What were the first foods i ntroduced:
	Age Began Sitting:
	Age Began Crawling:
	Age Began Walking:
	Age Began Talking:
	Sleep Pattern:
	Nightly Sleep (hours)
	First Words:
	Number of Naps:
	How long?

PATTERN OF REGULARITY
	Eating Times:
	Activity:
	Rest:
	Fresh Air and Excercise:
	Electromagnetic Stress: TV Time: Computer Time:
	Other:
CONSENT TO TREATMENT OF A MINOR

CONSENT: Check the box below

I am the parent or legal guardian of the patient mentioned in this form. I agree to allow Doctor Anca Martalog, Doctor of Naturopathic Medicine to study, evaulate and administer naturopathic care if necessary.

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