-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

  F

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:

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