HOMEOPATHY

Please complete the following questionnaire legibly and COMPLETELY. This form will become the
beginning of your chart and will help the doctor to determine the cause of your problems.
ALL ITEMS MUST BE COMPLETED.

PERSONAL HISTORY

Date : 05 Apr 2004		Birth Date : ________/_________/_____
Name : ______________________________ Address : _____________________________ City : ________________________________ Prov : ___ Postal Code : _______________		Home Phone : ( ___ ) ______________ Bus. Phone : ( ___ ) ______________ Fax Number : ( ___ ) ______________ E-mail : __________________________
Present MD : _________________________ Phone Number : ( ___ ) ______________		Sex : M F Height _______  Weight _______
# of Children : Ages : ___/___/___/___		Check One: Married Single Widowed Divorced Separated
Business/Employer : _______________________________________ Type of Work : _________________________
Last Grade Completed : ___		If child, lives with : ________________
Mother's Name : _______________________ Father's Name : ____________________		Name of person responsible for bill: ____________________________________ Address if different from above : ____________________________________ ____________________________________ ____________________________________ ____________________________________
Insurance Company : ________________ Policy No. __________________________

Referred to this office by:

MEDICAL/PROFESSIONAL WAIVER
PLEASE READ THE FOLLOWING CAREFULLY
"If under 18 years old, a parent or guardian must sign."

I the undersigned, understand that Medolie Cannon is a homeopathic doctor and not a licenced medical doctor. As such, I acknowledge that it is my responsibility to seek medical diagnosis and advice for my present and future conditions. In consulting with Melodia Cannon, I am exercising my right to choose an alternative method of treatment through which to addres my total health. As homeopathy is not covered by the existing goverment insurance plan, I agree to pay all fees presented in the current rate schedule ($90 for initial; $45 for follow-up; payable to Alliance Health Care).

Signature: ____________________________________________________ Date : _____/___/____

Current Complaint(s):
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When did the condition begin? ____________

Other personal health goals :
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MEDICATIONS
A. List any medications, their specific names, dosage, how often currently take. (Show brand names) and what you are taking them for.
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B. List any vitamin, mineral or nutrituinal supplement, their specifc names, dosage, and how often currently taken. (Show brand names).
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Have you ever been treated homeopathically before?
Homeopath : _____________ When : _______________
For : _______________ Remedies : _______________

VACCINATION HISTORY/CHILDHOOD
Illness:
Measles : Age when vaccinated for: Age When/if ill with: Reaction to vaccine?
Mumps : Age when vaccinated for: Age When/if ill with: Reaction to vaccine?
Rubella/Germ. Measles : Age when vaccinated for: Age When/if ill with: Reaction to vaccine?
Chicken Pox : Age when vaccinated for: Age When/if ill with: Reaction to vaccine?
Whooping Cough : Age when vaccinated for: Age When/if ill with: Reaction to vaccine?
Pneumonia : Age When/if ill with:
Mononucleosis : Age When/if ill with:
Additional vaccines : _______________
Any adverse effects from vaccinations?
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Are you currently under the care of another physician?
Who : _______________For what condition? _______________
Treatmeant :
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Who : _______________For what condition? _______________
Treatmeant :
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Check each of the following conditions you have had:
Abscesses Alcoholism Anemia Arthritis Asthma Cancer Chicken Pox
Cold Sores Colitis Depression Diabetes Emphysema Epilepsy Gallstones
Goitre Gonorrhea Gout Hay Fever Heart Disease Hepatitis Herpes Genitalia
Influenza Kidney Disease Leukemia Malaria Measles Miscarriage
Mononucleosis Mumps Parasites Pleurisy Pneumonia Prostatitis
Rheumatic Fever Rubella Scarlet Fever Sexual Abuse Skin Disease Strep Throat
Sinusitis Stroke Syphilis Tonsilitis Tuberculosis Typhoid Fever
Venereal Warts Warts Whooping Cough Worms Yellow Fever

Are there any of the preceding conditions after which you have never been totally well again?
  Y N                   If YES which ones:
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How many hours do you sleep daily? (including naps) _______________
What time do you go to sleep? _______________
Do you awaken feeling rested? Y N
What type of work do you do? _______________
Do you enjoy your work? Y N Sometimes
How many hours each day do you work? _______________
At what times do you start and end work? Start -_______________ End - _______________
Do you smoke? Y N If yes, how much? _______________
If no, does anyone in your household and/or workplace smoke? Y N
What do you do for exercise? (Indicate type, frequency, and time)
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Do you actively participate in any spiritual discipline (church, religous group...)? Y N
Do you have any allergies? Y N           If so please list:
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HEALTH HISTORY
P = Patient ~ Sp = Spouse ~ M = Mother ~ F = Father ~ S = Sibling

History	P	Sp	M	F	S	Please Explain Specific Diagnosis
Allergies						_______________
Asthma						_______________
Birth Defects						_______________
Blood Diseases (anemia, hemophilia, etc.)						_______________
Bone or joint disorders						_______________
Cancers, tumours, malignancies						_______________
Chronic lung diseases (asthma, T.B. etc)						_______________
Eye or ear disorders						_______________
Glandular diseases (thyroid, diabetes,etc)						_______________
Heart trouble						_______________
Kidney or urinary disease (bladder problems, cystitis)						_______________
Mental Retardation						_______________
Muscle disease (weakness, poor control)						_______________
Nerve disease (epilepsy, cerebral palsy, others)						_______________
Psychiatric condition						_______________
Vaginal discharge, yeast infection						_______________
Venereal disease (S.T.D.)						_______________
HIV Positive - AIDS						_______________
High blood pressure						_______________
Gastro-intestinal disorders (ulcers, diverticulitis, Crohn's disease, irritable bowel syndrome, colitis)						_______________
Skin Disorders (exzema, psoriasis, rashes)						_______________
Liver disease (hepatitis, cirrhosis, jaundice)						_______________
Mononucleosis						_______________
Polio Myelitis						_______________
Coxsackle virus						_______________
Herpes						_______________
Migrain headaches						_______________
Alcoholism						_______________
Other						_______________

MAJOR HOSPITALIZATIONS
If you have ever been hospitalized for any medical illness or operation, write down hospitalizations below:

	YEAR	OPERATION OR ILLNESS
1st hospitalization (most recent)	_______________	_______________
2nd hospitalization	_______________	_______________
3rd hospitalization	_______________	_______________

OUTPATIENT SURGERY:

	YEAR	OPERATION OR ILLNESS
1st surgery (most recent)	_______________	_______________
2nd surgery	_______________	_______________
3rd surgery	_______________	_______________

Please complete the following. Leave blank if symptom or activity does not apply. 1 for mild or rarely occurring, 2 for moderate or regularly occuring, 3 for severe or often occuring.

CANDIDIASIS

extreme fatigue	1 2 3	abnormal muscle aches from exercise	1 2 3
recurrent vaginal infection	1 2 3	excessive wax in ears	1 2 3
frequent use of antibiotics	1 2 3	unexpected/unexplained weight gain	1 2 3
white coated tongue, oral thrush	1 2 3	impotence	1 2 3
crave sugars, bread, alcohol	1 2 3	canker sores	1 2 3
headaches	1 2 3	athlete's foot, finger/toenail fungus, ringworm	1 2 3
tonsillitis, recurrent strep throat	1 2 3	jock itch	1 2 3
itchy, watery or dry eyes	1 2 3	"brain fog"	1 2 3
skin flushes	1 2 3	irritability	1 2 3
chronic indigestion, frequently use antacids	1 2 3	memory loss	1 2 3
		mental cofusion	1 2 3
		F: PMS	1 2 3
always cold, espcially in extremities	1 2 3	depression or anger for no reason	1 2 3
		pain in pelvic area	1 2 3
anxiety/panic attacks	1 2 3	abdominal gas and bloating	1 2 3
inability to concentrate	1 2 3	loss of sex drive	1 2 3
phobic/compulsive	1 2 3	cystitis, repeated bladder infection	1 2 3
lethargy	1 2 3	increasing food and chemical sensitivities; severe reaction to tobacco, perfume etc.	1 2 3
mood swings	1 2 3
itchy ears, nose, anus	1 2 3	F: endometriosis/ovary problems	1 2 3
hives, psoriases, acne, skin rashes	1 2 3	chronic diarrhea	1 2 3

PARASITES

forgetfulness	1 2 3	pain in the back, thighs, shoulders	1 2 3
slow reflexes	1 2 3	numb hands	1 2 3
gas and bloating	1 2 3	drooling while sleeping	1 2 3
unclear thinking	1 2 3	damp lips at night	1 2 3
loss of appetite	1 2 3	dry lips during the day	1 2 3
yellowish or pale face	1 2 3	grind teeth while asleep	1 2 3
fast heartbeat	1 2 3	bedwetting	1 2 3
heart pain	1 2 3	lethargy: chronic fatigue	1 2 3
pain in the navel	1 2 3	dark circles under eyes	1 2 3
eating more than normal but still feeling hungry	1 2 3	cancer	1 2 3
		blurry or unclear vision	1 2 3

Can you have a good night's rest, wake up in the morning and still feel tired? Y N
Do you have problems with short term memory? Y N
Do you have greater emotional swings than what you think you should? [By this we mean emotional simulation (your ups) or emotional depression (your downs)]. Y N
Do you not tolerate the cold? ie.e do you need to wear more clothes than others in order to stay warm? Y N
Do you think your reflexes (your neuromuscular responses) are as quick as they used to be?
Y N
Are you gaining more weight that you think you should for your calorie intake? Y N

ALLERGIES

acne, psoriasis, dermatitis, exzema	1 2 3	excessive sweating, night sweats	1 2 3
rapid pulse, heart irregularities	1 2 3	bowel disease, IBS, IBD, Crohn's, etc.	1 2 3
frequent headaches	1 2 3	joint pains or stiffness	1 2 3
hay fever	1 2 3	frequent night urination	1 2 3
frequent cravings for certain foods	1 2 3	wheezing	1 2 3
periods of blurred vision	1 2 3	pale face	1 2 3
repeated ear trouble	1 2 3	hives	1 2 3
hyperactivity	1 2 3	nose runs costantly	1 2 3
dizzy spells	1 2 3	noticable chagnes in writing throughout the day	1 2 3
periods of confusion	1 2 3	nosebleeds	1 2 3
poor concentration	1 2 3	bloating or gas after earing certain foods	1 2 3
epilepsy	1 2 3	canker sores	1 2 3
muscle cramps or spasms	1 2 3	dark circles under eyes	1 2 3
abnormal body odour	1 2 3	stuffy nose	1 2 3

UNDERACTIVE THYROID/HYPOTHYROID

distinct, lethargic tiredness or sluggishness	1 2 3	hair dry, brittle, dull, lifeless	1 2 3
cold hands or feet	1 2 3	flaky, dry, rough skin	1 2 3
mercury amalgams (fillings)	1 2 3	feel stiff after sitting still for some time	1 2 3
gain weight easily, fail to lose on diets	1 2 3	mood swings	1 2 3
constipation, less than one bowel movement a day	1 2 3	unusually square and wide fingernails	1 2 3
low energy in the morning	1 2 3	high cholestoral	1 2 3
low pulse rate	1 2 3	dimished sex drive	1 2 3
low body temperature, especially at bed rest	1 2 3

OVERACTIVE THYROID/HYPOTHYROID

losing weight without trying	1 2 3	nervous behaviour, hyperactivity	1 2 3
heart races while at rest	1 2 3	insomnia	1 2 3
feel warm/flushed at room temp	1 2 3	increased appetite	1 2 3
hands shake or tremble	1 2 3	frequent bowel movements, diarrhea	1 2 3
protruding tongue	1 2 3	excessive sweating without exercising	1 2 3
heart palpitations	1 2 3

PITUITARY

infertility or impotence	1 2 3	excessive urination	1 2 3
headaches affecting one side of head	1 2 3	pain in little finger of left hand	1 2 3
F: loss of menstrual function	1 2 3	swelling in ankles, fingers, feet or under	1 2 3
moody	1 2 3	cold hands or feet	1 2 3
overweight from waist down	1 2 3	pain in left side of upper neck	1 2 3
overweight from waist up	1 2 3

ADRENALS

stress or emotional upsets cause exhaustion	1 2 3	bow lines (depressed furrows) on fingernails	1 2 3
blood pressure decreases when going from a lyihg position to a standing position	1 2 3	tightness or lump in throat, especially when emotionally disturbed	1 2 3
perspire excessively	1 2 3	high or low blood pressure	1 2 3
neck and/or shoulder tension	1 2 3	rapid pulse	1 2 3
frequent headaches	1 2 3	short temper	1 2 3
occasional cold sweats	1 2 3	puffy face	1 2 3

STRESS

	YES	NO	COMMENTS
Home:
Mild			______________________________________________
Moderate			______________________________________________
Severe			______________________________________________
Work:
Mild			______________________________________________
Moderate			______________________________________________
Severe			______________________________________________
School:
Mild			______________________________________________
Moderate			______________________________________________
Severe			______________________________________________
What are the major causes or factors of your stress?
Financial			______________________________________________
Career			______________________________________________
Personal			______________________________________________
Marriage			______________________________________________
Health			______________________________________________
Family			______________________________________________
Spiritual			______________________________________________
Unfulfilled expectations			______________________________________________

Parents, please fill out below for information on your child.
Adults, please fill out below, regarding your infancy, if the information is availble to you.

Patient's Birth History	YES	NO	Don't Know
During the pregnancy with patient, did mother
have high blood pressure?
have diabetes or surgar in her urine?
have albumin or protein in her urine?
have a urinary infection?
have German (3 day) measles?
take medicines prescribed by her doctor?
frequently smoke cigarettes?
if YES, about how many packs a day?	______
have a venereal disease such as gonorrhea or syphilis?
have a dependence on drugs or alcoholic beverages?
Other conditions:
How long was pregnancy?	______	mo.
How early did mother start seeing the doctor?	______	mo.
Did patient have hiccups while in mom's uterus?
Was this patient premature?
Was more than one baby born?
Did mother have a difficult delivery?
Was it a breech (bottom first) delivery?
Was it a cesarean delivery?
What was patient's weight at birth?	______
Was there an Rh problem?
Was anything wrong with patient at birth?
If Yes, what? _______________

Maternal and Family History of Patient:
How many children have you (mother) had? _______________
Which one is this child? _______________
Have you (mother) had any premature births? Yes No
Have you (mother) had any miscarriages? Yes No
Mother's age now : _______________
Father's age now: _______________
Number of people living in child's house : _______________
Who spends most time caring for child: _______________

Introduction of Foods:
(circle) This patient was bottle / breast fed.
If bottle fed, which formula was used? _______________


Did you have to switch/try other formulas? Yes Which ones?
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This patient had _______________
At what age did the patient start solid foods? _______________
Did the patient have any problems with solid foods? Yes No
If yes, list the foods:
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List any foods omitted from the diet during early childhood or infancy. If omitted why?
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Dietary Habits
How many times a day do you eat:

Main Meals _______________
Snacks _______________
Please list what you would typically eat for:
Breakfast:
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Lunch:
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Dinner:
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At what time do you have your last meal or snack of the day? _______________
Do you eat or use:
Fried foods Refined foods Luncheon Meats Cigarettes Candy Microwave
Aluminum Pans Margarine Nutra-sweet/aspartame Fast foods
Please indicate how many cups of the following you drink per day:
___ Beer
___ Red Wine
___ Coffee
___ White Wine
___ Tap Water

___ Other Alcoholic Bev
___ Diet Pop
___ Pop
___ Tea
___ Fresh Fruit Juice

___ Prepared Fruit Juice
___ Milk 2%
___ Bottled/Spring Water
___ Herbal Tea

___ Skim Milk
How many servings of fresh fruit and/or vegetables do you eat in a day?
___
Are you a Meat Eater? Vegetarian Vegan
How often do you meat? Daily 3-5 times a week Once a week or less
What are your favourite foods?
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Do you experience any symptoms if missed? Yes No      If yes, what:
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Do you avoid certain foods? Yes No       If so why?
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What symptoms, if any do you experience after a meal?
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Please list any foods you eat excessively, i.e. once daily or more often.
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Which food would you miss the most if taken out of your diet? ____________________________________________________________

 232 South Service Road ~ Oakville, Ontario  L6J 2X5 Canada
tel: 905-845-2291 fax: 905-845-5606
[email protected]