Adult Intake Form

Dr. Cassandra Connolly BSc, ND
6777 Quinpool Road
Halifax, NS
T: (902) 407-3347
Fax: (902) 407-3348

Fees and Cancellation Policy
Initial Visit - Adult w/ Dr. Connolly $180.00
Initial Visit – Child w/ Dr. Connolly $150.00
Subsequent visit - Adult $95.00
Subsequent visit- Child $80.00

Failure to show up for scheduled appointment: Full Fee
Appointment cancelled within 24 hours of appointment: Half Fee

This fee is to cover the practitioner’s time, as these appointment slots will not be filled by other patients in need or on the waiting list.

A minimum of 24 hours is required for the cancellation of an appointment in order to facilitate the filling of this spot with another patient.

While we do make every effort to contact patients in the days preceding their appointments, this confirmation should not eliminate the responsibility of the patient to take note of and attend their appointments.

If you need to cancel an appointment, please leave a message on our voicemail at (902) 407-3347 or speak with the receptionist.

We appreciate your understanding and cooperation.

Intake Form
Please note that this intake form will take time to complete accurately. This form also requires the entry of a 3-day Diet Diary. You may scroll down to the bottom of the page to see the requirements of this diary before completing.

* Indicates required field

Name (first and last) *

Age *

Birthdate *

Address *

City *

Postal Code *

Phone (home) *

Phone (work) *

Is it OK for us to leave messages? *

Yes No

Email *

I would like to receive the clinic's monthly newsletters & occasional wellness tips *

Yes

Insurance

Insurance Company *

Policy/Plan Number *

Credit Card
In order to direct bill your insurance company on your behalf we require a credit card be left on file.

Plan Holder's Name *

Identification Number *

Name on Card *

Card Number: *

Expiry *

CVV (3 digits on back of card) *

Occupation *

Employer *

Other/Comments *

Number of children *

Emergency Contact *

Relation to you *

Phone *

How did you find out about Dr. Connolly? *

Last medical check-up *

Last visit to a Medical Doctor *

Date of last bloodwork *

Blood type (if known) *

Current Health Issues

What is your main reason for coming in today? *

List in order of importance other health problems that are troubling you.

1. Issue and when is started affecting you *

2. Issue and when is started affecting you *

3. Issue and when is started affecting you *

4. Issue and when is started affecting you *

5. Issue and when is started affecting you *

Please list other health care practitioners you see or have seen in the past 3-4 years: *

Please rate the state of your health *

Score you current level of energy from 1 – 10 (10 being the highest) *

What is your current weight? *

What was your weight one year ago? *

What is your ideal weight? *

What is your height? *

Which of the following do you currently use?
Please indicate:
- The amount
- Frequency
- How long you have been using

Alcohol *

Hormones *

Cortisones *

Sedatives *

Recreational drugs (which ones) *

Tobacco *

Coffee/Tea *

Laxatives *

Antacids *

Medications (please give name, dose and amount of time you have been taking) *

Supplements/Vitamins/Herbs Medications (please give name, dose and amount of time you have been taking) *

List the most significant/stressful events in your life (please include event and date occurred) *

What are your main interests/hobbies? *

What is the greatest source of stress in your life? *

Who do you live with? *

Ailments (please indicate if you've experienced them in the past, present or both)

Allergies *

Asthma *

Eczema *

Psoriasis *

Ear Infection *

Strep Throat *

Hay Fever *

Measles *

Mumps *

Chicken Pox *

Whooping Cough *

Diptheria *

Scarlet Fever *

Sinusitis *

Canker *

Acne *

Tonsilitis *

Weight Problems *

Gallstones *

Gout *

Arthritis *

Thyroid Problems *

Anemia *

High Blood Pressure *

Rheumatic Fever *

Fainting *

Poor Memory *

Balance Problems *

Speech Problems *

Ringing In The Ears *

Jaundice *

Hepatitis *

Alcoholism *

Stroke *

Cancer *

Epilepsy *

Migraine *

Pneumonia *

Diabetes *

Malaria *

Tuberculosis *

Small Pox *

Polio *

Parasites *

Gas/Bloating *

Hemorrhoids *

Herpes *

Veneral Disease *

Syphillis *

Gonorrhea *

Miscarriage *

Headaches *

Alopecia (hair loss) *

Varicose veins *

Broken Bones *

Numbness *

Tingling *

Cold Hands *

Cold Feet *

Visual Problems *

Warts *

Mono *

Depression *

Anxiety *

Sexual Abuse *

Emotional Abuse *

Rape *

Child Abuse *

Please list any allergies you have to medications, food, chemicals, animals, etc. *

Digestion

Do you (burp, have gas, feel uncomfortable) after eating? *

Yes No

How often do you experience this problem? *

Always Sometimes Never

How often do you have bowel movements? *

Please check if you have any of the following: *

Blood Mucus Undigested Food Black Stool

Do you have rectal itching? *

Yes No

Please check if you have the following: *

Formed stool Loose stool Diarrhea

Do you ever have any alternating constipation and diarrhea? If so, how often? *

Does your gas have a strong odour? Do you have gas frequently? *

General Health History

Do you Exercise? *

Yes No Sometimes

If yes/sometimes, what type of exercise do you do, and how often? *

How many glasses of water do you drink per day on average? *

How would you rate your sleep? (10 being great) *

How many hours of sleep per night do you get? *

Do you nap or rest during the day? If so, how long? *

What is your body temperature? *

Cold Warm Hot

How many times per year do you get a cold or flu? *

When was the last time you were on an antibiotic and what was it for? *

Reproductive

Are you currently sexually active? *

Yes No

Do you use birth control? If YES, what type of birth control? *

Female

Age of first menses *

If periods have stopped, at what age did they stop? *

Are your cycles regular? *

Yes No

Please indicate when your periods begin and how many days they last *

Are your periods: *

Heavy Medium Light

What colour is the blood? *

Are there any clots? *

Yes No

Do you have cramps with your period? *

Yes No

Do you have any spotting or bleeding between periods? Please indicate if it occurs every month *

Yes Every Month No

Other *

Number of pregnancies *

Number of abortions *

Number of miscarriages *

Number of live births *

Any problems becoming pregnant *

Do you get regular Pap smears? Please indicate if any have been abnormal *

Yes No Have been abnormal

Do you do regular self breast exams? Please indicate if you have noticed any breast lumps *

Yes No I have noticed breast lumps

Do you have any concerns with libido? *

Yes No

If so, when did it begin? *

Do you experience pain with intercourse? *

Yes No

If so, what type of pain? *

Male

How often do you get up in the night to urinate? *

Has this increased recently? *

Yes No

Do you have any problems with impotency? (Achieving or maintaining an erection) *

Yes No

Do you have abnormal discharge from your penis? *

Yes No

Have you had your prostate examined? *

Yes- no issues Yes- there has been issues identified No

Do you have any fertility issues? *

Decreased semen output Concerns with sperm motility Concerns with sperm quantity None

Kidney and Bladder

Have you ever had bladder infections? *

Yes No

If yes, how many and how was it treated? *

Do you experience a burning sensation during/after urinating? *

Past Present Currently

Do you have difficulty stopping or starting urination? *

Yes No

Environment

Is your home damp or mouldy? *

Yes No

Do you work in an office building? *

Yes No

Does where you work, live or do hobbies expose you to chemicals or fumes? *

Yes No

Is there anything else you feel I should know about your health? *

Diet Diary
Please write down everything you ate and drank (with portion sizes) in the past 3 days. Please be honest and as accurate as you can in your recording. Hovering your mouse over the question mark icon will give you further instructions if you need it.

Day One *

Day Two *

Day Three *

Additional Notes *

Choose Any *

I have read and agree to the cancellation policy

I agree to receiving marketing and promotional materials

Submit

Dr. Cassandra Connolly​Adult Intake Form

Intake Form Please note that this intake form will take time to complete accurately. This form also requires the entry of a 3-day Diet Diary. You may scroll down to the bottom of the page to see the requirements of this diary before completing.

Insurance

Credit Card In order to direct bill your insurance company on your behalf we require a credit card be left on file.

Current Health Issues

Digestion

General Health History

Reproductive

Female

Male

Kidney and Bladder

Environment

Diet DiaryPlease write down everything you ate and drank (with portion sizes) in the past 3 days. Please be honest and as accurate as you can in your recording. Hovering your mouse over the question mark icon will give you further instructions if you need it.

Dr. Cassandra Connolly
Adult Intake Form

Intake Form
Please note that this intake form will take time to complete accurately. This form also requires the entry of a 3-day Diet Diary. You may scroll down to the bottom of the page to see the requirements of this diary before completing.

Credit Card
In order to direct bill your insurance company on your behalf we require a credit card be left on file.

Diet Diary
Please write down everything you ate and drank (with portion sizes) in the past 3 days. Please be honest and as accurate as you can in your recording. Hovering your mouse over the question mark icon will give you further instructions if you need it.