WellnessPlus Genomics Client Intake Form

Hidden

Date*

Section 1: Personal Information

Patient Name*

Date of Birth*

Alberta Health Care No.*

Weight*

Unit of measurement for weight*

Height*

Unit of measurement for weight*

Address*

Phone*

Email*

How Did You Hear About Us

Drug Insurance

Or attach an image of your Drug Insurance

Max. file size: 1 GB.

Relationship status:

Single
Married
Common-Law
Divorced

Household demographics (ie: spouse, underaged children, pets etc.)*

Occupation

Hours of work per week

Family Doctor*

Last Family Doctor Visit

Other Health Care Providers

Female: Are you pregnant or breastfeeding?

Yes
No

Allergies (food, drugs, environmental etc.)?*

Yes
No

Drug allergies?*

Yes
No

List drug allergies*

Food allergies?*

Yes
No

List of food allergies*

Environmental allergies (including animals)?*

Yes
No

List of environmental allergies (Including animals)*

How do you currently manage your environmental allergies?*

Are your environmental allergies intolerable?*

Yes
No

How would you rate your current health?*

Poor
Fair
Good
Excellent

Rate your stress:*

Low
Average
High
Unbearable

Sources of Stress (Check all that apply)*

Work
Family
Health
Money
All of the above
Other

If you have other sources of stress, what are they?

Do you have difficulties getting things done under pressure?*

Yes
No

Do you use relaxation techniques regularly?*

Yes
No

How would you describe your energy level in general?*

Low Energy
Medium Energy
High Energy

Exercise*

Do you currently use tobacco products?*

Yes
No

Are you signing up for our Tobacco Cessation Program?*

Yes
No

Type of tobacco products using currently (Check all apply)*

Cigarettes
Cigars/ Cigarillos
Chew tobacco
E-cigarettes/ Vape
Pipe
Other

Other types of Tobacco products

How many years have you been using tobacco products?*

How many cigarettes or tobacco products do you use per day?*

Does anyone use tobacco products in your house?*

Yes
No

What is your relationship with the person(s) who smoke in the house?*

What have you done previously to try to quit your tobacco use?*

Never tried anything
Acupuncture/ Herbal
Hypnosis
Laser
Pharmaceuticals such as Champix/ Zyban/ NRT
Cold Turkey
Taper down
Counselling/ Classes/ Friends/ self-help
Other

Other previous quit smoking trials

Comments for previous treatments if applicable*

Include effectiveness of previous treatment or approaches, why do you think some of the previous approaches failed/ helped?

When was your last quit attempt?*

How long was your longest quit attempt*

Past relapse reasons (check all that apply)

Discharge from Health Care site
Withdrawal Symptoms
Stopped medications/ behavioral support
Use of alcohol/ other drugs
Household smoker
Family/ friends smoker
Stress
Other

Other past relapse reasons*

List the good things about using tobacco products*

List the bad things about tobacco products*

Barriers to quitting tobacco products (Check all that apply)*

Other barriers to quitting smoking*

Stressors to use tobacco products (Check all that apply)*

No Stressor, I enjoy smoking
Financial
Work or unemployment
Mental illness
Physical illness
Housing
Family
Other

Other Stressors to smoke not listed

How confident are you to quit in the next 30 days?*

How motivated are you to quit in the next 30 days?*

Do you currently consume alcohol?*

Yes
No

If yes, do you have concerns with consuming alcohol?

Do you currently consume caffeinated products?*

Yes
No

How much caffeine do you consume per day?*

Do you currently use cannabis products?*

Yes
No

Is it for medical use or recreational?*

Medical
Recreational
Both Medical and Recreational

Section 2: Medical Conditions

Family History (Check all that apply)*

RA/ OA or not sure

Rheumatoid Arthritis
Osteoarthritis
Not sure

Other Type of Heart Disease*

Types of Cancer*

Other Family history*

Please check off if you have any of the following Medical Conditions:*

If you have any addictions, what are they?

Other Medical Conditions

Do you have any unusual body aches/ pain and or swollen joints?*

Yes
No
I am not sure

Do you currently have any issues relating to hormones?*

Yes
No
I am not sure

Please explain your hormone issues here if applicable.*

Do you currently have any issues relating to your immune system?*

Yes
No
I am not sure

immune issues

Do you frequently experience any of the mood issues? (Check all that apply)*

Restlessness
Irritability
Sadness
Boredom
None of the above

Do you get distracted easily or have difficulty stay focused?*

Yes, all the time
Yes, sometimes
No, never

Sleep (Check all that apply)*

I have insomnia every night
I do not have any sleep concerns at this time
I feel rested when I wake up in the morning on MOST days
I fall asleep but I wake up often and am not able to fall back asleep on MOST nights
I am not able to fall asleep but when I do, I stay asleep on MOST nights
Other

Other sleep concerns

Hours of sleep per night*

Do you have sleep apnea?*

Yes
No
I am not sure

What do you current do to manage sleep apnea?

Current list of prescription medication:

Current list of supplements or nutraceuticals:

List 3 current health concerns (list in primary order)*

What have you previously tried to address your concerns?

Upload any relevant info

Aka. lab work, food sensitivity, tests, etc.

Drop files here or

Max. file size: 1 GB, Max. files: 5.

Section 3: Gastrointestinal Health

Do you have any gastrointestinal issues?*

Yes, please describe below
No

GI issues*

Do you have the following weight management issues?*

I am not able to LOSE weight
I am not able to GAIN weight
I am content with my weight

How many meals do you eat per day?*

How many snacks do you eat per day?*

What percentage of your meals are prepared/ packaged food or foods from restaurants each week?*

0-25%
26-50%
over 50%

Do you get noticeably irritated, weak or lightheaded if you haven't eaten in a while?*

Yes
No

Eating tendencies (Check all the apply)*

None
Binge eat
Not eating enough
Eating too much

Do you have follow specific diet restrictions or diet plans?*

Yes, please describe below
No

Diet plans/ diet restrictions*

Do you crave certain foods? (Check all that apply)*

Sweets
Chocolate
Bread/Pasta
Fried Foods
Alcoholic Drinks
Sodas/Diet Sodas
Meat
Other

Other food cravings*

Are your nails weak or brittle?*

Yes
No

Bowel Movement (Check all that apply)*

Formed. Once - twice daily. No concerns
I have constipation on most days in a week
I have diarrhea everyday in a week
I have loose stool on most days in a week
I have a mix of constipation and diarrhea throughout the week

To what extent will you commit to achieving better health?*

Little
Moderate
Major
Extreme

Behaviours Past or Present

Additional information

Section 4: Declaration of Consent

Declaration and Consent of Resident or Resident’s Substitute Decision Maker (as applicable)

Informed Consent*

Functional Medicine is the treatment and prevention of diseases by natural means as a whole. At Sage Plus, our Clinical Pharmacists will assess the whole person, taking into consideration physical, mental, emotional and spiritual aspects of the individual. We use gentle, non-invasive techniques to stimulate the body's inherent healing capacity. There are some health risks involved when you choose any type of medicine and naturopathic medicine is not an exception. These risks include but are not limited to : aggravation of pre-existing symptoms; allergic reactions to supplements/ herbs or pain etc. I understand that a record will be kept of the health services provided to me and this record will be kept confidential. I understand that the results are not guaranteed. I do not expect the Clinical Pharmacist to be able to anticipate and explain all risks and complications. With this knowledge, I voluntarily consent to naturopathic interventions offered by Sage Plus Clinical Pharmacy. I intend this consent to cover the entire course of treatment. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time. I understand that the decision to discontinue prescription medications or any other prescribed medical treatment is my own responsibility. If I forego standard medical treatment in favor of natural therapies, I assume responsibility for any potential risk that may entail. Sage Plus Clinical Pharmacy will explain procedures, probable outcomes and possible risks whenever possible.

Yes, I consent - see signature below

Consent*

I give Sage Plus Clinical pharmacy the access to all my information via NETcare*

Signature*

Name*

Date of Consent*

Comments

This field is for validation purposes and should be left unchanged.