ADULT INTAKE FORM

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First Name
Your First Name
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Last Name:
Your Last Name
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Age
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Date of Birth:
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Gender:
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Care Card:
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City
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Postal Code:
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Phone Number (home)
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Status

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Address:
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Province:
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Email:
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Phone Number (cell):
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Live With

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Education:
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Occupation:
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Hours per week
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Employer:
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How did you hear about the Brio Health Clinic?
  • Google Search
  • Recommend from a friend
  • Social Media: Facebook, Instagram
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Next of kin or other to reach in an emergency
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Relationship:
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Phone Number:
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Address:
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CANCELLATION POLICY
I understand that I am responsible for paying the cost of the visit, before the next appointment, if I do not give 24 hours notice by phone of change or cancellation. Payment for all treatment, whether private or insured, is ultimately the responsibility of the patient.
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CONSENT
I hereby consent to receive treatments by the practitioners at Brio Integrative Health Centre. I understand that this consent is voluntary and may be revoked by me at any time. I authorize the clinic and its associated practitioners to collect my personal and medical information as documented above in order to contact me, and give permission for the clinic to leave messages regarding appointments at any of the contacted numbers I have provided.
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I consent to the following:

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Date:
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CONTEXT OF CARE REVIEW
Successful health care and preventive medicine are only possible when the physician has a complete understanding of the patient physically, mentally and emotionally. The nature of your responses to the following questions will go along way in assisting my understanding of your truest desires. Your time, thoughtfulness and honesty in completing this overview will greatly aid me to assist your health needs.
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Why did you choose to come to this clinic?
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What do you know about our approach?
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What three expectations do you have from this visit to our clinic?
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What long term expectations do you have from working with our clinic?
...
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What expectations do you have of me personally as your physician?
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What is your present level of commitment to address any underlying causes of your signs and symptoms that relate to your lifestyle?
(Please use the slider below to indicate your level of commitment. 0 = not commited,10 = 100% committed)
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What behaviors or lifestyle habits do you currently engage in regularly that you believe support your health? (please list)
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What behaviors or lifestyle habits do you currently engage in regularly that you believe are self destructive lifestyle habits (please list)
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What potential obstacles do you foresee in addressing the lifestyle factors which are undermining your health and in adhering to the therapeutic protocols which we will be sharing with you?
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Who do you know that will sincerely support you consistently with the beneficial lifestyle changes you will be making?
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Are you currently receiving healthcare?
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If yes, where and from whom
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If no, when and where did you last receive medical or health care?
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What was the reason?
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What are your most important health problems? List as many as you can in order of importance:
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Do you have any known contagious diseases at this time?
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If yes, what?
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General

Height:
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Weight:
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Weight one year ago:
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Max weight:
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When?
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Min weight:
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When?
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When during the day is your energy the best?:
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Worst?
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TYPICAL FOOD INTAKE

Breakfast
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Dinner:
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Snack:
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Beverage:
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FAMILY HISTORY

Cancer
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Kidney disease
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Tuberculosis
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Tuberculosis
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Asthma/Hay fever/Hives
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Diabetes
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Epilepsy
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Stroke
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Arthritis
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Mental illness:
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High blood pressure
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High cholesterol
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Anemia
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Any other relevant family history?
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What is your ethnic heritage?
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CHILDHOOD ILLNESSES

Have you had any of these as a child or as an adult? Please indicate age if you have had childhood ilnesses as and adult
Scarlet Fever
  • Child
  • Adult
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Age
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+
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Diphtheria
  • Child
  • Adult
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Age
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+
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Rheumatic fever
  • Child
  • Adult
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Age
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+
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