New Patients

All New Patients MUST complete this intake form prior to their Initial Consultation.  If you have any questions, pleae click on the contact tab to the left to speak with us directly.

E-mail Address: * Please tell us who you were referred by. * How did you first hear about us? Salutation * Dr. Mr. Mrs. Ms. First Name * Middle Name * Last Name * Address * Province * Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan --Territories-- Northwest Territories Nunavut Yukon Country * Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua & Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahama Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Iislands Costa Rica Cote D'ivoire (Ivory Coast) Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard & McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iraq Ireland Islamic Republic of Iran Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova, Republic of Monaco Mongolia Monserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Lucia Samoa San Marino Sao Tome & Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka St. Helena St. Kitts and Nevis St. Pierre & Miquelon St. Vincent & the Grenadines Sudan Suriname Svalbard & Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Togo Tokelau Tonga Trinidad & Tobago Tunisia Turkey Turkmenistan Turks & Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom (Great Britain) United States Minor Outlying Islands United States of America United States Virgin Islands Uruguay Uzbekistan Vanuatu Vatican City State Venezuela Vietnam Wallis & Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe Primary Daytime Phone Number * Marital Status * Single Married Divorced/Seperated Widow/Widower Occupation * Please List Your Primary Health and Treatment Concerns and the Issues You Want to Discuss During Your Appointment * Primary Disease Diagnosis * Describe all Disease Symptoms * Have you ever been diagnosed with any type of cancer? Please type yes or no. * Yes No Current status of your cancer? Please list any treatment questions you may have. Please list all supplements you take including Brands and dosage. Please list all medications you are on currently. Please list all previous medications (past 10 years.) Do you have any special needs such as assistance walking, use a wheelchair or other? Neurological History * Dizziness Decreased Vision Black of Blind Spots in Vision Muscle Weakness Muscle Wasting Walking Difficulties Decreased Hand Strength Fainting Speech Difficulties Tingling Sensations Muscle Fasciculations Spasticity Hyperreflexia Hyporreflexia Depression Loss of Memory Headaches/Migraine Sleep Disturbance None Pulmonary History * Asthma Bronchitis Chronic Cough Emphysema Tuberculosis None Cardiac History * Myocardial Infarction Angina Pectoris Tachycardia ByPass Surgery Hypertension Hypotension None Circulatory History * Poor Arterial Circulation Poor Venous Circulation Varicose Veins Leg Cramps Tired Legs Swollen Ankles Leg Ulcers Tingling in Legs and Feet Falling Asleep of Hands and Feet None Gastrointestinal History * Acid Indigestion/Reflux Bloating Diarrhea Stomach or Duodenal Ulcer Loss of Appetite Rapid Weight Loss Rapid Weight Gain Overweight Problems Have had a gastroscopy or colonoscopy Hepatitis Gall Bladder Surgery Gall Stones Gas None Upper Respiratory * Chronic Cold Chronic Sinusitis Chronic Sinus Headache Allergic Rhinitis Nose Bleeds Allergic Sinus None Endocrine/Hormone Health * Hyperthyroid Hypothyroid Male Menopause Female Menopause Diabetes Type II Adrenal Gland Dysfunction Other None Allergy History * Food Allergies - especially egg Vaccine Reactions Hayfever Allergic Asthma Medication Reactions None Medication Reaction Detail - Please list all. Dental History * Amalgam Fillings (Metal) Root Canals Chronic Gum Infection Dental Implants None Surgical History - Please list procedures and dates. Family History * Diabetes Cancer Mental Health Stroke Heart Problems High Blood Pressure Thyroid Problems Hormone Problems Lung Problems Kidney Problems Stroke Prostate Problems Breast Health Problems Anxiety Fatigue Viral Problems None or Unknown Diet - Please describe your daily eating habits briefly. Discuss examples of the meals and beverages you are likely to consume daily. * Date of Birth * Please state the purpose of your appointment. Initial Consultation - Dr. Fox Initial Intake - Stem Cell Treatment Medical Thermography - Breast Medical Thermography - Full Body Medical Thermography - Area of Special Interest Medical Thermography - Upper or Lower Body Verification Code: Enter Verification Code: * * Required