Intake form

General Health History

Date:_____________________

Name________________________________________________(M) (F)

Date of Birth: ___________ Age: ____ Birthplace:___________________

Address:____________________________________________________

Phone (h):__________________________(c)______________________

e-mail _____________________________________________________

Occupation:_________________________________________________

Name of Doctor/Specialist: _____________________________________ phone:_____________________________________________________

Name of other Health Practitioners: ______________________________

Emergency contact: _________________________phone:____________

Referred by:_________________________________________________

What is the main condition for which you are seeking treatment?

___________________________________________________________

___________________________________________________________

What is the history of this condition (ie. when did it start, what makes it worse/better?

what have you already tried for treatment?)

____________________________________________________________

What is the history of this condition (ie. when did it start, what makes it worse/better?

what have you already tried for treatment?)

___________________________________________________________

___________________________________________________________

___________________________________________________________

Previous Medical History:

List any previous illnesses including childhood illness or chronic viral infections, any surgeries, traumas or accidents, even if unrelated to your current condition.

___________________________________________________________

___________________________________________________________

___________________________________________________________

Are there any conditions that are significant in your family’s medical history?

(eg. heart disease, cancer, stroke, high blood pressure, kidney disease, diabetes, asthma, ulcers, mental/emotional disorders, etc)

__________________________________________________________

__________________________________________________________

Please list any allergies and the reaction you have:

___________________________________________________________

___________________________________________________________

Please be assured that your information is confidential and will be shared only with your practitioners.

Lotus Arts and Wellness, 94 Cumberland St. Suite 805, Toronto, 647 428-7200