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Patient Intake Form
Assured your responses will be kept confidential and released only with your prior permission, please supply the following information:
Sex
Full Name
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Case History
Today's Date
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Your Date of Birth
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Height
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Weight
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Age
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Marital Status
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Full Address
Please enter your full address including Street, City, Province and Postal Code
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Home Phone
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Work Phone
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Mobile Phone
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May health related telephone/e-mail messages may be left for you?
Email Address
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Referred by
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Emergency Contact Name
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Emergency Contact Phone Number
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Your Occupation
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Your Employer
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Names and specialties of your other health care providers
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Your health concerns, in order of importance
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If female, are you currently pregnant?
Indicate serious past illnesses, injuries and hospitalizations
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List medicinal, environmental and food allergies
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List all current medications (prescription, over-the-counter, vitamins, herbs, homeopathics, etc)
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Tobacco
Indicate how much of the following substances you are using (/wk., /mo., /yr.)
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Alcohol
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Pain Medication
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Do you have regular screening tests done by a medical physician? (annual physical examinations, blood tests, etc.)
Do you have regular six-month dental cleanings and examinations?
Body Systems Review
Below, please describe any problems you have with headaches, hair loss, nose and sinuses [pain,discharge (colour), post nasal drip, blockage], sense of smell and taste, ears [pain, plugged, hearing, ringing, dizziness], eyes [vision, styes, watering], throat [pain, cough, clearing], facial or oral skin eruptions [acne, cold sores, canker sores], sleep disturbance, stiff neck and dental health. Have you had any metallic dental fillings or root canals? Below the head area, do you have any difficulty in the chest with breathing or voice [lungs, bronchial tubes, trachea, larynx], heart [pain, skipped or irregular beats, racing, pounding], any chest pain [front, back or sides], shoulder/arm/elbow/wrist/hand/finger problems? From the abdomen, do you have any pain, indigestion, heartburn, burping, lower gas or bloating? Do you eat a lot of certain foods or have food cravings? What is your level of thirst? How often do the bowels move and is there any difficulty with them or with the bladder and how many times are you up at night to urinate? Do you have any problems with pain, stiffness or other problems with the legs, knees, ankles and feet, toes? Body-wide do you have any skin, hair or nail problems or temperature difficulties [generally too hot or too cold or both in an alternating fashion]? What is your over-all energy level? Do you have any other problems that are of concern?
Your answer
Consent to Naturopathic Diagnostic / Therapeutic Procedures
Attending N.D. Dr. Richard Putnam

RECOMMENDED DIAGNOSTIC / THERAPEUTIC PROCEDURE(S)
(including those by referral to another practitioner)

The therapies offered at this office are:
Homeopathic and/or Herbal Medicines and/or Dietary Changes

I do hereby acknowledge that I have been informed of and understand the recommended diagnostic / therapeutic procedure(s) described above from reading Dr. Putnam’s website information and have discussed to my satisfaction this and any requests for related information with the Naturopathic Doctor named above and/or with his/her office or clinical assistant(s). I further acknowledge and confirm that, through other information provided on the website from which this form was downloaded I have been informed of, and understand the procedure(s) with respect to the nature of the procedure, expected benefits, potential risks, side effects and financial cost; the likely consequences of not having the procedure(s), and what alternative course(s) of action are available to me. I understand that I can withdraw my consent at any time.As a result, I do hereby voluntarily provide my informed consent for the recommended procedure(s) specified above.

I do hereby acknowledge that I have been informed of and understand the recommended diagnostic / therapeutic procedure(s).
Patient Consent Form for Collection, Use and Disclosure of Personal Information
Privacy of your personal information is an important function of this office, while providing you with quality naturopathic care. We understand the importance of protecting your personal information responsibly. We will try to be as open and transparent as possible about the way we handle your personal information.

In this Clinic, Dr. Richard Putnam, acts as the Privacy Information Officer.

All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are trained in the appropriate use and protection of your information.

Our privacy policy outlines what our Clinic is doing to ensure that:

- only necessary information is collected about you;
- we only share your information with your consent;
- storage, retention and destruction of your personal information complies with existing legislation, and privacy protection protocols;
- our privacy protocols comply with privacy legislation and standards of our regulatory body, the Board of Directors of Drugless Therapy – Naturopathy.

How Our Clinic Collects, Uses and Discloses Patients’ Personal Information

Our Clinic understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined here how our Clinic is using and disclosing your information.

This Clinic will collect, use and disclose information about you for the following purposes:
- to assess your health concerns
- to provide health care
- to advise you of treatment options
- to establish and maintain contact with you
- to send you newsletters and other information mailings
- to remind you of upcoming appointments
- to communicate with other treating health-care professionals and billing
- to communicate with insurance providers
- to comply with legal and regulatory requirements of our regulatory body, - the Board of Directors of Drugless Therapy – Naturopathy acting under the authority of the Drugless Practitioners Act
- to invoice for goods and services
- to process credit card/debit payments
- to collect unpaid accounts
- to assist this Clinic to comply with all regulatory requirements
- to comply generally with the law
- to allow potential purchasers, practice brokers to conduct an audit in preparation for a practice sale

By completing the consent section of this Patient Consent Form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal information as outlined above.

Patient Consent
I have reviewed the above information that explains how your Clinic will use my personal information, and the steps your Clinic is taking to protect my information.
I agree that Dr. Richard Putnam can collect, use and disclose my personal information as set out above in the information about the Clinic’s privacy policies.
Disclaimer
Medicine, like other professions that study nature, such as astronomy, weather prediction, farming and gardening, is not an exact science. Understanding human physiology and the factors that disturb it, causing illness and disease, is an extremely complex subject that has challenged the best minds for centuries. Consequently, health providers and students are to-day confronted with a wealth of accumulated literature that a lifetime of pure study would fail to exhaust. The dizzying multitude of both conventional and alternative therapies is the evidence of this complexity.

The reality of this circumstance dictates that even the most brilliant doctors, despite years of education, find themselves humbled to a position where from they can but merely attempt to cure or alleviate their patients’ conditions. All that doctors are able to do is simply try to help their patients. Often they are successful, and often they are not. Evidence of this unspoken reality comes from the administrative offices for the various health professions which firmly instruct all their doctors to offer no absolute certainty of health results thereby potentially raising false hope.

Given these facts, this health practitioner endeavors to provide the best possible diagnosis and course of treatment understanding that many known and quite possibly unknown factors will be important in determining actual results. Therefore, no guarantee can be made with respect to any assessment methods, treatment or application of health care advice, financial costs or information given.

Acknowledging your understanding of this matter and your wish to proceed with your health care from this office, please select your response below
Thank You
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