Forms

Short Intake Form: Your Health Information

Please take a few brief moments to complete the following short intake form before your first visit. This allows Dr. Berchman to get a health overview to best prepare for your visit.

Name: *
What health concern(s) would you like to discuss?
Any previous injuries / hospitalizations / surgeries?
Current medications / supplements:


Please indicate if you are currently experiencing, or have previously experienced, the following:



General Symptoms


Fainting | Dizziness
Numbness | Tingling
Frequent infections
Loss of sleep
Loss of weight
Night sweats

Lungs


Asthma | Bronchitis
Chronic cough
Spitting up blood
Wheezing
Pain of breathing
Shortness of breath

Skin


Rashes | hives | itching
Bruises easily
Colour changes

Stomach | Gut


Indigestion
Nausea | Vomiting
Abdominal bloating
Abdominal cramps
Constipation
Diarrhea
Hemorrhoids
Gallbladder problems
Liver problems

Muscles | Joints


Muscle weakness
Joint pain | stiffness
Spasms | cramps
Shoulder pain
Back pain
Arthritis
Stiff Neck
Gout
Swollen joints

Women's Health


Painful periods
Irregular cycle
Excessive flow
Vaginal discharge
Birth control
Pregnancy
Gender: *
Date of Birth *
 /  / 
E-mail: *
Rate your overall energy:
Rate your stress level:
Rate your overall health:
How active is your lifestyle?
Do you consume alcohol? Amount per week?
Do you smoke? Cigarettes per week?







Please indicate if you are currently experiencing, or have previously experienced, the following:



Head | Neck


Headache | Migraines
Enlarged glands
Vision Problems
Sinus problem
Impaired Hearing
Ear Pain | Discharge

Heart


Heart disease
High blood pressure
Poor circulation
Anemia
Angina | chest pain
Varicose veins
Swelling of ankles
Irregular heart beat
Bleeding disorder

Hormones


Cold | heat intolerance
Hypoglycemia
Hyperthyroidism
Hypothyroidism
Diabetes
Hormone replacement

Brain | Nerves


Loss of balance
Convulsions
Speech problems
Loss of memory
Involuntary movement
Paralysis

Kidneys


Pain on urination
Incontinence
Urgency | hesitancy
Blood in urine
Pus in urine
Kidney stones
Increased frequency
Frequency at night
Frequent infections

Men's Health


Testicular pain | masses
Penile discharge
Erectile dysfunction


Word Verification

Please press "Submit" to send your form to
Dr. Berchman Wong

Thank you for taking the time in completing
your short intake form online. The information
you provide will be kept strictly confidential.