Adult Intake Form

Please have this form completed for your initial visit. Indicate N/A for items that you feel are nonapplicable.

Name: Shaina Agbayani

Age: 19

Date of Birth: 12/28/1991

Sex:

Address/Postal Code 10 Chasser Drive, Markham, Ontario, L6E1K4 Phone (H) Phone (W) Phone (cell) 51416189743

Fax

May I leave you me ssages in regards to your app ointments? yes Email shainaagbayani@gmail.com Occupation Student Place of Work McGIll Emergency Contact Name E de l Ag b ay a ni Emergency Contact Number 9 0 5 2 0 9 0 5 9 0 R e lation Mother Marital Status/Living Arrangement Single Family Physician Phone Other Health Care Practitioners Have you seen a Naturopathic Doctor before? \yes How did you hear about this clinic? Internet Fax Phone

Health Concerns (Please list in order of importance) 1.Psoriasis 3. 2. BPA level of blood Medical History Date of last physical exam: Height: 51.5 Current medications + dosages (including over-the-counter): 4. Co

5.Colon Health 6.

Weight: 110

Past medications: How many times have you been treated with antibiotics? Current supp lements or herbal products + dosages: Fish Oil 3X a day, borage oil 3X a day, multivitamin 3X a day, chlorophyll 2X a day, evening primrose oil 3X day, probiotics once a day List any known allergies: From what you recall, please circle the childhood infections that you have experienced: Measles / German Measles / Chicken Pox / Mumps / Whooping Cough / Rheumatic Fever / Diphtheria / Scarlet Fever / Polio Other: Please list any major lab testing or medical procedures performed in the last 3 years? Traumas/Surgeries/Accidents/Diseases: Please list all major acc idents, hospitalizations, surgeries, diseases and traumatic events, and your age at the time: Please continue on the back of this page if you require add itional space. 1. Drug Poisoning Age: 19 2. Age: Age: 3. Age: 4. Age: 5.

Family Medical History: Please check the app ropriate box if you or a family mem ber have had any of the following conditions:
Adara Integrative Cl inic | 1920 Yonge Street, Suite 105 | Toronto, Ontario M4S 3E2 tel. 416.367.1500 | fax. 416.367.8888 | www.adarac l ini c.ca

You Alcoholism Anemia Arthritis (Osteo or Rheumatoid) Asthma/Allergies Autoimmune Disease (Lupus, etc) Cancer (Give type) Chronic Fatigue/Fibromyalgia Depression/Mood swings Diabetes Eczema/Psoriasis Heart disease/Angina/ High blood pressure Kidney Disease Osteoporosis Schizophrenia/Delusions/Alzheimers Thyroid abnormalities Tuberculosis/Lung Disease Other: Lifestyle

Mother

Father

Sister/Brother

Grandparents

yes

Yes

Yes Yes

Yes

Yes

Do you smoke cigarettes? No If yes, how many cigarettes per day? Do you use recreational drugs? N If yes, please specify: Do you drink alcoho l? N If yes, how much alcohol per week: Have you ever been treated for an add iction to drugs, alcoho l, or prescription medications? N How many times do you exercise per week? 1 What form of exercise? Walking or Biking How many hours do you sleep per night? 7 Do you have dif ficulty falling asleep Yes How often do you wake through the night? Twice Do you awake in the morning feeling rested? Som etim es On a scale of 1-10 (10 is highest) rate your energy levels in the morning 5 Please list the top three sources of stress in your life: 1) School afternoon 6 2) Parents evening 8 3)

Do you experience depression? Y es Do you experience mood swings? Y es Have you experienced mental, emotional, or sexual abuse? N o Have you received psychiatric/psychological counseling? Y es What do you do in your leisure time? Read, eat, cook, piano, sing What do you do to relax? The above Environment List any household pets: No Seasonal allergies NO If yes, please specify: Are you af fected by scented products/perfumesYes Please circle all that app ly to your living environment: apartment Approximately what year was your home or dwelling built? Many diff homes Are chemicals used on your lawn/garden? N o What is your source of drinking water? Tap Are you exposed to any chemicals/hazardous materials on a regular basis? No How would you describe the emotional climate in your home? Supportive yet stressful List factors in your home/work environment that might adversely affect your health/well-being? Relationship Strain

Nutritional Habits
Adara Integrative Cl inic | 1920 Yonge Street, Suite 105 | Toronto, Ontario M4S 3E2

tel. 416.367.1500 | fax. 416.367.8888 | www.adarac l ini c.ca

Briefly describe a typical days diet: Breakfast: Soy millk, chia, gluten free cereal Lunch: salad and beans Dinner: carrots, beets, chickpeas, kale, with quinoa Snacks: tortilla and almond butter! Beverages: water, soya milk (the Asian pure form!) How much water do you drink each day? Just around 8 glasses Please list your favorite foods: Do you have food cravings? Y es If so, list foods: Bread, cereal, Do you drink cof fee? N o so, how many cups per day? List any known food allergies or intolerances: List dietary restrictions (religious/vegetarian/vegan, etc.)? Vegetarian and avoiding gluten due to psoriasis! How many bowel movements do you have a day? Do you experience diarrhea / constipation? (circle)

Please use the space below to indicate any add itional information:

Much of whats listed here diet for instance and supplements are very recent changes due to psoriasis And home related questions may not be too telling as Ive moved around much over the past 3 years!

Thank you for taking the time to complete this intake form.

Adara Integrative Cl inic | 1920 Yonge Street, Suite 105 | Toronto, Ontario M4S 3E2 tel. 416.367.1500 | fax. 416.367.8888 | www.adarac l ini c.ca