- stethoscope2

ASHIT KAPADIA BHMS,ND

Email mynaturopath@gmail.com Tel 416-707-6656

NATUROPATHIC DOCTOR

Original Date:

HEALTH HISTORY QUESTIONNAIRE

All questions contained in this questionnaire are strictly confidential
and will become part of your medical record.

Name (Last, First, M.I.):

Santokie, Kara

DOB:

21st November 1980

Address:

23-464 Spadina Road

Home Phone: 647-704-1754 Work Phone: Cell Phone:

Marital status:

◻ Divorced

Emergency Contact:

Phone:

Referring doctor:

Dr Kirsten Smith

Date of last physical exam:

Other Health Care providers (Name, Designation, Phone): Dr Sara Taman, Albany Medical Clinic

PERSONAL HEALTH HISTORY

Childhood illness:

Chickenpox

Immunizations and dates:

◻ Tetanus

YES

◻ Pneumonia

◻ Hepatitis

◻ Chickenpox

◻ Influenza

◻ MMR Measles, Mumps, Rubella

YES

List any medical problems that other doctors have diagnosed

Surgeries

Year

Reason

Hospital

Other hospitalizations

Year

Reason

Hospital

List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers
Name the Drug			Strength			Frequency Taken
Resotran			1 mg			1 daily or 1 every other day
Antimicrobials for Small Intestinal Bacterial Overgrowth			various
B12			5000 mg			daily





Allergies to medications
Name the Drug			Reaction You Had




HEALTH HABITS AND PERSONAL SAFETY

All questions contained in this questionnaire are optional and will be kept strictly confidential.
Exercise	◻ Sedentary (No exercise)
	◻ Mild exercise (i.e., climb stairs, walk 3 blocks, golf)
	◻ Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.)
	◻ Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes)
Diet	Are you dieting?							◻	Yes	◻	No
	If yes, are you on a physician prescribed medical diet?							◻	Yes	◻	No
	# of meals you eat in an average day? 2, sometimes 3
	Rank salt intake	◻ Hi		◻ Med	◻ Low
	Rank fat intake	◻ Hi		◻ Med	◻ Low
Caffeine	◻ None	◻ Coffee 1 cup		◻ Tea	◻ Pop/Soda
	# of cups/cans per day?
Alcohol	Do you drink alcohol?							◻	Yes	◻	No
	If yes, what kind?
	How many drinks per week?
	Are you concerned about the amount you drink?							◻	Yes	◻	No
	Have you considered stopping?							◻	Yes	◻	No
	Have you ever experienced blackouts?							◻	Yes	◻	No
	Are you prone to “binge” drinking?							◻	Yes	◻	No
	Do you drive after drinking?							◻	Yes	◻	No
Tobacco	Do you use tobacco?							◻	Yes	◻	No
	◻ Cigarettes – pks./day			◻ Chew - #/day	◻ Pipe - #/day		◻ Cigars - #/day
	◻ # of years	◻ Or year quit
Drugs	Do you currently use recreational or street drugs?							◻	Yes	◻	No
	Have you ever given yourself street drugs with a needle?							◻	Yes	◻	No
Sex	Are you sexually active?							◻	Yes	◻	No
	If yes, are you trying for a pregnancy?							◻	Yes	◻	No
	If not trying for a pregnancy list contraceptive or barrier method used: CONDOM
	Any discomfort with intercourse?							◻	Yes	◻	No
	Illness related to the Human Immunodeficiency Virus (HIV), such as AIDS, has become a major public health problem. Risk factors for this illness include intravenous drug use and unprotected sexual intercourse. Would you like to speak with your provider about your risk of this illness?
								◻	Yes	◻	No
Personal Safety	Do you live alone?							◻	Yes	◻	No
	Do you have frequent falls?							◻	Yes	◻	No
	Do you have vision or hearing loss?							◻	Yes	◻	No
	Physical and/or mental abuse have also become major public health issues in this country. This often takes the form of verbally threatening behavior or actual physical or sexual abuse. Would you like to discuss this issue with your provider?
								◻	Yes	◻	No

FAMILY HEALTH HISTORY

	Age	Significant Health Problems		Age	Significant Health Problems
Father	68	Diabetic, Alcoholism	Children	◻ M ◻ F
Mother	66	High Blood Pressure, Stroke, Neuralgia,		◻ M ◻ F
Sibling	◻ M ◻ F	Back pain, arthritis, ovarian cysts		◻ M ◻ F
	◻ M ◻ F	Ovarian Cysts		◻ M ◻ F
	◻ M ◻ F		Grandmother Maternal
	◻ M ◻ F		Grandfather Maternal
	◻ M ◻ F		Grandmother Paternal
	◻ M ◻ F		Grandfather Paternal

MENTAL HEALTH

Is stress a major problem for you?	◻	Yes	◻	No
Do you feel depressed?	◻	Yes	◻	No
Do you panic when stressed?	◻	Yes	◻	No
Do you have problems with eating or your appetite?	◻	Yes	◻	No
Do you cry frequently?	◻	Yes	◻	No
Have you ever attempted suicide?	◻	Yes	◻	No
Have you ever seriously thought about hurting yourself?	◻	Yes	◻	No
Do you have trouble sleeping?	◻	Yes	◻	No
Have you ever been to a counselor?	◻	Yes	◻	No

WOMEN ONLY

Age at onset of menstruation: 13
Date of last menstruation: 7th July 2018
Period every ___30-34__ days
Heavy periods, irregularity, spotting, pain, or discharge?	◻	Yes	◻	No
Number of pregnancies _____ Number of live births _____ Number of Miscarriages____ Number of Abortions____
Are you pregnant or breastfeeding?	◻	Yes	◻	No
Have you had a D&C, hysterectomy, or Cesarean?	◻	Yes	◻	No
Any urinary tract, bladder, or kidney infections within the last year?	◻	Yes	◻	No
Any blood in your urine?	◻	Yes	◻	No
Any problems with control of urination?	◻	Yes	◻	No
Any hot flashes or sweating at night?	◻	Yes	◻	No
Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period?	◻	Yes	◻	No
Experienced any recent breast tenderness, lumps, or nipple discharge?	◻	Yes	◻	No
Date of last pap and rectal exam? Pap July 2018

MEN ONLY

Do you usually get up to urinate during the night?	◻	Yes	◻	No
If yes, # of times _____
Do you feel pain or burning with urination?	◻	Yes	◻	No
Any blood in your urine?	◻	Yes	◻	No
Do you feel burning discharge from penis?	◻	Yes	◻	No
Has the force of your urination decreased?	◻	Yes	◻	No
Have you had any kidney, bladder, or prostate infections within the last 12 months?	◻	Yes	◻	No
Do you have any problems emptying your bladder completely?	◻	Yes	◻	No
Any difficulty with erection or ejaculation?	◻	Yes	◻	No
Any testicle pain or swelling?	◻	Yes	◻	No
Date of last prostate and rectal exam?	◻	Yes	◻	No

OTHER PROBLEMS

Check (√) Y if you have the symptom now, and P if the symptom is in the past.

SKIN	Y
Rashes
Hives
Acne
Boils
Eczema
Psoriasis
Dry Skin
Itching
Lumps
Night Sweats
Other

HEAD	Y
Tension Headache
Migraine Headache
Head Injury
Dizziness
Other: TMJ

EYE	Y
Impaired Vision
Use of Contact Lenses
Eye Pain
Tearing
Dryness
Double Vision
Glaucoma
Cataracts
Blurring
Light Sensitive
Itching
Redness
Discharge
Blind Spot
Other

EARS	Y
Impaired Hearing
Earache
Dizziness
Discharge
Infection
Excessive Wax
Other: Tinnitus

NOSE & SINUSES	Y
Frequent Colds
Nose Bleeds
Stuffiness
Hay Fever
Infections
Other

MOUTH & THROAT	Y
Hoarseness
Gum Problems
Difficulty Swallowing
Dental Problems
Sores
Dryness
Sore Throat
Loss of Taste
Other

NECK	Y
Lumps
Swollen Glands
Goiter
Pain or Stiffness
Other

RESPIRATORY	Y
Cough
Sputum
Spitting up Blood
Wheezing
Asthma
Bronchitis
Pneumonia
Pleurisy
Emphysema
Difficulty Breathing
Pain on Breathing
Shortness of Breath
Shortness of Breath at Night
Shortness of Breath when Lying
Positive Tuberculin Test
Last TB Test
Last Chest X-Ray
Other

CARDIOVASCULAR	Y	P
Angina
Murmurs
Chest Pain
Swelling in Ankles
Palpitations, Fluttering
Last ECG
Other

BREAST	Y	P
Do you do self breast exams?
Lumps
Tenderness
Pain (or Tenderness)
Nipple Discharge
Last Mammogram
Other

GASTROINTESTINAL	Y
Trouble Swallowing
Heartburn
Change in Appetite
Nausea
Vomiting
Vomiting Blood
Belching
Passing Gas
Abdominal Pain
Indigestion
Diarrhea
Constipation
Blood in Stool
Hemorrhoids
Black Tarry Stools
Jaundice
Liver Disease
Gallbladder Disease
Food allergy
Hiatus Hernia
Last Colonoscopy 2008
Other: Small Intestinal Bacterial Overgrowth; IBS; multiple food and chemical sensitivities; bloating;

BLOOD & LYMPHATIC	Y
Anemia
Easy bruising/bleeding
Past Blood Transfusions
Lymph Node Swelling
Other

URINARY
Pain on Urination
Increased Frequency
Increased Frequency at Night
Inability to Hold Urine
Frequent Infections
Kidney Stones
Blood in Urine
Reduced Urine Flow
Other
















FEMALE REPRODUCTIVE	Y
Bleeding Between Periods
Irregular Cycles
Pain during Intercourse
Painful Menses
Excessive Flow
PMS
Difficulty conceiving
Sexual Difficulties
Vaginal Discharge
Vaginal Itching
Check sexual Preference:
Heterosexual
Homosexual
Bisexual
Menopause (Age of Onset)
Hormone Therapy
Last Gynecological Exam JULY 2018
Last Pap Test JULY 2018
Other

MUSCULOSKELETAL	Y
Broken Bones
Muscle Spasm/Cramps
Weakness
Joint Swelling
Backache
Other: JOINT PAIN

PERIPHERAL VASCULAR	Y
Deep Leg Pain
Cold Hands/Feet
Varicose Veins
Thrombophlebitis
Leg Cramps
Numbness in Hands and Feet
Coldness in Hands and Feet
Swelling in Hands and Feet
Ulcers in Hands and Feet
Other

NEUROLOGIC	Y
Fainting
Seizures/Convulsions
Paralysis
Muscle Weakness
Numbness or Tingling
Loss of Memory
Involuntary Movement
Loss of Balance
Speech Problems
Other

ENDOCRINE	Y
Heat or Cold Intolerance
Thyroid Problems
Excessive Thirst
Excessive Hunger
Excessive Urination
Excessive Sweating
Diabetes
Hypoglycemia
Hormone Therapy
Other

EMOTIONAL	Y
Depression
Anger
Mood Swings
Anxiety
Nervousness
Tension
Phobias
Insomnia
Sexual Difficulties
Drug Abuse
Psychiatric Care
Psychological Counseling
Other

Release of Records

I authorize Ashit Kapadia, Naturopathic Doctor, to obtain a copy of all diagnostic test results from the last 12 months.

Please send records to:

Ashit Kapadia,BHMS,HD,ND,

Su Sarvam Naturopathic Clinic

201-1110 Sheppard Ave East

North York, ON, M2K2W2

Phone: 416 492 4424

cell: 416 707 6656

mynaturopath@gmail.com

Name:______________________________	DOB (DD/MM/YY):___/___/___	Home Ph.#:___________________
Address:______________________________	City:_________________________
_____________________________________	Postal Code:___________________	Work Ph.#:____________________
_____________________________________	Province:______________________

Medical/Naturopathic Doctor:______________________________		Phone #:______________________
Address:______________________________	City:_________________________
_____________________________________	Postal Code:___________________	Fax #:________________________
_____________________________________	Province:______________________
		Email:_________________________

Patient signature: _______________________ Date (DD/MM/YY):_______________

Witness signature: _______________________ Date (DD/MM/YY):_______________

Fee Schedule

Initial Naturopathic Consultation

Initial 120 minute consultation: $250

Subsequent Consultations

45-60 minutes/3-4 weeks apart: $120

45-60 minutes/6-8 weeks apart or more: $150 or more depending on remedies prescribed/length of time dispensed for

Acupuncture initial: $120

Acupuncture treatment: $65

Scheduled Telephone Consultations

Same charges apply to planned phone consultations

Cancellation of Appointments

Please give at least 24 hours notice to avoid standard charges for the appointment.

Laboratory Testing
Blood, urine, saliva and stool test are available through your naturopathic doctor. Naturopathic tests can measure toxicity level, digestive function, biological aging, stress level, nutritional status, sleep quality, hormone balance, etc… The cost for these tests varies.

Supplements
Some professional grade natural products are available through your naturopathic doctor. Most products are free of chemicals and additives as well as hypoallergenic (do not contain yeast, corn, starch, wheat, dairy, sugar, salt or gluten). The cost of these products varies. You have the option of purchasing products at your health food store or pharmacy of choice. Your ND will recommend the best brands.

Payments

All fees are subject to GST.

Visa,Mastercard,Cash and Cheques.

I, _______________________ , have read and agree to the fee schedule as listed above.

Signature:_______________________ Date(DD/MM/YY):_______________

Consent Form

I voluntarily consent to the procedures and treatments by Naturopathic Doctor Ashit Kapadia, which can include any combination of the following: medical history, physical exam, diagnostic testing, botanical medicine, homeopathy, traditional Chinese medicine, clinical nutrition, hydrotherapy, lifestyle counselling and coaching, psychological analysis, physical therapies, mind-body medicine, Reiki, if applicable.

I understand the following:

My medical records will be kept confidential and will not be released to anyone without my consent, unless required by law or I am at risk of harming myself or others. In order to ensure optimal care, Naturopathic Doctors may consult with other professionals about my case.

Naturopathic medicine can be used to help prevent and treat illnesses. However, Naturopathic Doctors cannot guarantee results of treatment.

Complications are very rare when treated by a licensed Naturopathic Doctor. Naturopathic Doctors cannot anticipate all risks and complications associated with treatment; however, they will do their best to inform me of the most common side-effects.

I am responsible for informing the above Naturopathic Doctor if my condition or medications change, (especially an anticipated pregnancy), as treatments may be contraindicated in some conditions.

I agree to pay for charges incurred during each visit by the end of the visit unless alternate arrangements have been made prior to my scheduled appointment. I will be provided with a receipt upon payment so that I can bill my insurance company. I will be charged additional fees for laboratory testing as well as supplements/homeopathic remedies/herbal medicines. I will also be charged for missed appointments, late cancellations (less than 24 hours) and overdue payments.

The clinic will endeavor to collect and maintain accurate personal information about me for the purpose of assessing my health concerns, advising me of my options, providing high quality natural and professional healthcare, maintaining contact with me, facilitating practice management and complying with naturopathic regulations.

Name: ________________________________ DOB (DD/MM/YY): _____________

Signature:______________________________ Date (DD/MM/YY): _____________

Witness signature: _______________________ Date (DD/MM/YY): _____________

Naturopathic Therapies

Licensed Naturopathic Doctors are primary care practitioners who use a combination of traditional medicine and modern research to prevent, diagnose, and treat illness naturally for the entire family. Naturopathic Doctors assess the whole person, taking into consideration physical, mental, emotional, and spiritual aspects. Gentle, non-invasive techniques are used in order to stimulate the body’s self-healing capacity. I will be using one, or a combination of the following naturopathic therapies, for your treatment plan.

Botanical Medicine is the use of constituents from whole plants (flowers, roots, and/or leaves) in the form of liquid tinctures, herbal teas, tablets, salves, essential oils, and baths and is based on both traditional practices and modern scientific research. Naturopathic Doctors are trained in the appropriate use of medicinal plants as well as drug-herb interactions. Botanical medicine is used to support and promote the healing processes which naturally exist within the body.

Homeopathy is a form of medicine which relies on minute amounts of substances to facilitate the body's natural healing capacity. Homeopathic remedies are prescribed based on the understanding that ‘like cures like’ - a principle which has been observed clinically for over 200 years. The selection of a remedy is based on the client’s entire symptom picture. The focus of homeopathy is to restore health to the entire body.

Traditional Chinese Medicine includes acupuncture, herbal formulas and dietary changes to eliminate disease and balance body functions. TCM involves an ancient system of diagnosis based on specific patterns and combinations of symptoms that have been observed over thousands of years. Acupuncture refers to the insertion of sterilized needles at specific points which modify the flow of energy through the body and stimulate organ function. In some cases, moxa (a compressed herb in the form of a stick) is burned over an acupuncture point to help relieve symptoms. Herbal formulas may be given in the form of pills, tinctures or strong teas to be taken internally or used externally as a wash. Dietary advice is based upon traditional Chinese medical theory.

Clinical Nutrition is the foundation of optimal health. Many conditions may be prevented or treated by modifications in diet alone, while others may require the prescription of specific nutrients. Nutritional analysis, dietary plans, cleansing / detoxification programs, and supplementation are tools used by a Naturopathic Doctor to address a variety of health concerns.

Hydrotherapy refers to the use of water applications at varying temperatures. Hydrotherapy is a noninvasive, economical and effective therapeutic approach that acts to stimulate the immune system, facilitate detoxification, and promote lymph drainage and circulation.

Lifestyle Counseling and Coaching is used to teach a client how to incorporate balance between work, nutrition, exercise, and activities of daily living. While the rewards are substantial, making changes in one’s lifestyle can be a challenge. It is important that the client be supported throughout this treatment process. Naturopathic care is a collaborative process between the client and doctor.

Massage and Body Adjustment is the use of hands-on therapies to adjust the joints and soft tissues of the body primarily to heal injury manage pain and relieve stress. These physical therapies can also have profound effects on restoring optimal nerve and organ function as well as stimulating circulation and detoxification.

Principles of Naturopathic Medicine

The following guiding principles are fundamental to every treatment plan.

First, do no harm

Promote optimal health with the least risk for each patient.

The healing power of nature

The healing power of nature must be respected to promote healing.

Treat the cause

Treat the fundamental cause of disease. Identify and remove the causes while avoiding the suppression of symptoms.

Doctor as teacher

The role of doctor as teacher and role model for patient education, for the inspiration of rational hope, and to encourage self-responsibility.

Treat the whole person

Address the unique physical, emotional, and mental factors which influence each person's well-being.

Prevention

Promote holistic health, to prevent future illness. Prevention involves individual, community, and global health promotion.

Su Sarvam Naturopathic Clinic, 201-1110 Sheppard Avenue East, North York, On, M2K 2W2

Tel 416-492-4423 Cell 416-707 6656 E-mail mynaturopath@gmail.com

Original Date:

HEALTH HISTORY QUESTIONNAIRE

All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

DOB:

Marital status:

Emergency Contact:

Phone:

Date of last physical exam:

PERSONAL HEALTH HISTORY

Childhood illness:

Immunizations and dates:

List any medical problems that other doctors have diagnosed

Surgeries

Other hospitalizations

List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers

Allergies to medications

HEALTH HABITS AND PERSONAL SAFETY

Exercise

Diet

Caffeine

Alcohol

Tobacco

Drugs

Sex

Personal Safety

FAMILY HEALTH HISTORY

Father

Children

Mother

Sibling

Grandmother

Grandfather

Grandmother

Grandfather

MENTAL HEALTH

WOMEN ONLY

MEN ONLY

OTHER PROBLEMS

All questions contained in this questionnaire are strictly confidential
and will become part of your medical record.