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Client Intake Form
Client Intake Form
sageplus
2020-12-01T15:49:17+00:00
Hidden
Date
*
DD slash MM slash YYYY
Section 1: Personal Information
Patient Name
*
First Name
Last Name
Date of Birth
*
DD slash MM slash YYYY
Alberta Health Care No.
*
Weight
*
Height
*
Allergies:
Attach an image of your Drug Insurance (optional)
Max. file size: 1 GB.
Phone
*
Email
*
Address
*
Home Address
City
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Family Doctor
Last Family Doctor Visit
DD slash MM slash YYYY
Other Health Care Providers
How Did You Hear About Us?
Do you currently use tobacco?
*
Yes
No
How many packs do you smoke per day?
Do you Vape at this time?
*
Yes
No
How motivated are you to quit in the next 30 days?
*
1 (Low)
2
3
4
5
6
7
8
9
10 (High)
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
Section 2: Chronic Medical Conditions
Please check off if you have any of the following medical conditions:
Hypertension
Diabetes Mellitus
COPD
Asthma
Anxiety
Depression
Panic
ADD/ADHD
Eating Disorders
Paranoia
Autism
Hallucinations
Personality Disorder
Bipolar
Primary Insomnia
Post Traumatic Stress Disorder
Dementia
Obsessive Compulsive Disorder
Schizophrenia
Addictions
Other*
Other medical conditions:
If you have any addictions, what are they?
Current list of prescription medication (list below or upload list at the end of this section):
Current list of supplements or nutraceuticals:
How would you rate your current health?
Poor
Fair
Good
Excellent
Rate your stress:
Low
Average
High
Unbearable
Sources of stress:
Work
Family
Health
Money
Other*
If you have other sources of stress, what are they?
Exercise:
*
Relationship status:
Single
Married
Common-Law
Divorced
Occupation
Hours of work per week
List 3 current health concerns (list in primary order)
*
What have you previously tried to address your concerns?
*
Upload any relevant info
i.e.: list of current prescription medication, lab work, food sensitivity, tests, etc.
Drop files here or
Select files
Max. file size: 1 GB, Max. files: 5.
Section 3: Nutrition Consultation
Are you signing up for a nutrition/weight management program?
*
Yes
No
Family History (check all that apply)
Stroke
High BP
Depression
Heart Disease
Arthritis (RA or OA)
Cancer
Diabetes
Weight Problems
Ulcer
Psoriases
Glaucoma
Other*
Type of Cancer
Family History - Other
Physical Status
Usual adult body weight
Highest weight
At age
Lowest weight
At age
Diet
Food allergies:
Food dislikes:
Do you get noticeably irritated, weak or lightheaded if you haven't eaten in a while?
Yes
No
Do you crave certain foods?
Sweets
Chocolate
Bread/Pasta
Fried Foods
Alcoholic Drinks
Sodas/Diet Sodas
Meat
Other*
Other foods craved:
How often do you have bowel movements?
Bowel movement frequency
Per Day
Per Week
Per Month
How many times do you urinate?
Urination frequency
Per Day
Per Week
Per Month
Dental health issues:
Prone to Cavaties
Gum Disease
Bleeding Gums
Are your nails week or brittle?
Yes
No
Hours of sleep per night:
To what extent will you commit to achieving better health?
Little
Moderate
Major
Extreme
Additional information
Section 4: Declaration of Consent
Declaration and Consent of Resident or Resident’s Substitute Decision Maker (as applicable)
Consent
*
I give Sage Plus Clinical pharmacy the access to all my information via NETcare
*
Signature
*
Name
*
Date of Consent
*
DD slash MM slash YYYY
Comments
This field is for validation purposes and should be left unchanged.
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