Microsoft word - lemmo intake form.doc

Dr. Walter Lemmo, ND, FABNO Lemmo Integrated Cancer Care Inc. 327 Renfrew Street TODAY’S DATE (MM/DD/YY)
HEALTH CARE NUMBER
REFERRED BY
BIRTH DATE (MM/DD/YY)
Contact Details
POSTAL CODE
TELEPHONE (HOME/BUSINESS/MOBILE)
EMAIL ADDRESS
WOULD YOU LIKE TO RECEIVE DR. LEMMO’S ONLINE NEWSLETTER VIA EMAIL? (PLEASE CIRCLE)
Emergency Contact
RELATIONSHIP TO YOU
TELEPHONE (HOME/BUSINESS/MOBILE)
Lifestyle
OCCUPATION(S)
HOURS PER WEEK
EDUCATION (LAST GRADE OR DEGREE COMPLETED)
STATUS (PLEASE CIRCLE)
SEXUALLY ACTIVE (PLEASE CIRCLE)
NUMBER OF CHILDREN
NUMBER OF SIBLINGS
Enrollment
REASON FOR VISIT
WHAT DO YOU EXPECT FROM THIS VISIT?
Dr. Walter Lemmo, ND, FABNO Lemmo Integrated Cancer Care Inc. 327 Renfrew Street ARE YOU WILLING TO MAKE LIFESTYLE AND DIET CHANGES? (PLEASE ELABORATE)
Medical History
SURGERIES (PLEASE INCLUDE APPENDIX, WISDOM TOOTH EXTRACTIONS, ETC.)
ACCIDENTS (MOTOR VEHICLE, TRAUMA, ETC.)
MEDICATIONS (LAST 24 MONTHS, INCLUDING ANTIHISTAMINES, ASPIRIN, TYLENOL, BCPS, ANTIBIOTICS, ZANTAC/TAGAMET)
SUPPLEMENTS (VITAMINS & MINERALS, HERBAL, HOMEOPATHICS, ETC.)
Family History
PLEASE SPECIFY TYPE AND RELATION OF FAMILY MEMBER TO YOU
Dr. Walter Lemmo, ND, FABNO Lemmo Integrated Cancer Care Inc. 327 Renfrew Street Medical Checkup History
FAMILY DOCTOR (NAME)
YOUR LAST GENERAL CHECKUP (MM/DD/YY)
DENTAL CHECKUP (MM/DD/YY)
EYE CHECKUP (MM/DD/YY)
HAVE YOU SEEN A NATUROPATHIC DOCTOR BEFORE? (PLEASE CIRCLE)
Cancer History (if applicable)
ARE YOU UNDER THE CARE OF AN ONCOLOGIST? (PLEASE CIRCLE)
HAVE YOU EVER RECEIVED TREATMENT FOR CANCER? (PLEASE CIRCLE)
ARE YOU CURRENTLY RECEIVING TREATMENT? (I.E. CHEMOTHERAPY OR RADIATION) (PLEASE CIRCLE)
IF NOT, WHEN WAS YOUR LAST TREATMENT? (MM/DD/YY)
Additional Medical Information
SERIOUS INFECTIONS (I.E. TB, MONO, PNEUMONIA, CHRONIC BRONCHITIS, ETC.)
ALLERGIES
HAVE YOU HAD LONG VISITS OR LIVED IN A FOREIGN COUNTRY? (PLEASE CIRCLE)
IF YES, WHICH COUNTRY, AND HOW LONG AGO? DO YOU USE… (PLEASE CIRCLE)
CIGARETTES? COFFEE? ALCOHOL? RECREATIONAL DRUG(S)? HOW DO YOU FEEL AFTER DRINKING COFFEE? (PLEASE CIRCLE)
NO EFFECT RACING HEARTBEAT HANDS SHAKE LIGHT-HEADED FEELING Dr. Walter Lemmo, ND, FABNO Lemmo Integrated Cancer Care Inc. 327 Renfrew Street Additional Medical Information (continued)
TIME YOU RETIRE (SLEEP)
TIME YOU WAKE-UP
DO YOU HAVE PROBLEMS… (PLEASE CIRCLE)
GETTING TO SLEEP? YES NO
STAYING ASLEEP? YES NO
DO YOU REMEMBER NIGHTLY DREAMS? (PLEASE CIRCLE)
YOUR BLOOD TYPE
EXERCISE (HOURS PER WEEK) (PLEASE CIRCLE)
WEIGHT: HAVE YOU EXPERIENCED CHANGES IN WEIGHT (INCREASE/DECREASE) DURING THE PAST 6 MONTHS?
HOW IS YOUR APPETITE?
HAVE YOU EXPERIENCED ANY RECENT NAUSEA OR VOMITING?
DO YOU SUFFER FROM PAIN? (PLEASE CIRCLE)
HAVE YOU HAD ANY FEVERS OF NIGHT SWEATS DURING THE PAST WEEK? (PLEASE CIRCLE)
HOW DO YOUR BOWELS CURRENTLY WORK? (PLEASE CIRCLE)
REGULAR DIARRHEA PRONE CONSTIPATION PRONE BOTH DOES GOING TO THE BATHROOM INTERFERE WITH YOUR SLEEP? (PLEASE ELABORATE)
ARE YOU CURRENTLY TAKING ANY PAIN KILLERS (PLEASE ELABORATE)
HOW MUCH WATER DO YOU DRINK PER DAY? (PLEASE ELABORATE)
How would you general y rate the occurrence of colds and flus that you have received throughout the years? Please circle all that applies to you. If you have been diagnosed with cancer, please rate the occurrence before your diagnosis. ALMOST NEVER How often do you receive the flu shot? Please circle al that applies to you. NEVER RARELY OFTEN ALMOST EVERY YEAR Dr. Walter Lemmo, ND, FABNO Lemmo Integrated Cancer Care Inc. 327 Renfrew Street An important note about Dr. Lemmo’s oncology practice Dr. Walter Lemmo is one of the few naturopathic physicians with an expertise and practice focused in cancer care in Canada.
In light of this, members of the standard oncology community (i.e. medical/radiation oncologist, haematologist, pharmacist,
oncology nurse, etc.) may regard Dr. Lemmo’s approach or recommendations as more experimental or controversial.
We have found throughout the years that these views largely depend on the person, their background, and what their school
of thought may be. Part of Dr. Lemmo’s value to people diagnosed with cancer is his knowledge of the general issues and
standard treatments in cancer care, combined with his expertise and clinical experiences in the area of naturopathic or
integrated cancer care, to further help guide clinical judgments.
There are many conflicting opinions and bodies of information available in print and online to navigate through and it is not the
intention to place a patient in the middle of any debate especially when going through cancer treatment(s). Ultimately, it is the
patient’s choice to decide on which direction or approach they would like to incorporate into their cancer care program.
Dr. Lemmo advises that a patient trust their personal intuition and to fol ow a recommended path that possess the greatest
comfort and the least amount of fear and stress in their cancer care journey whenever possible.
Please note that Dr. Lemmo is available to any healthcare professional or any part of a patient’s oncology team
(i.e. oncologist, haematologist, nurse, pharmacist, GP, etc.) at any time, if there is an area of concern, question or
harm. If such a situation arises, it is strongly urged that a telephone call be made to the office immediately and to
please not use any email or letter sent by the mail system.

By signing the below, you have read and understand this letter.
PATIENT’S FULL NAME
SIGNATURE
DATE SIGNED (MM/DD/YY)
Dr. Walter Lemmo, ND, FABNO Lemmo Integrated Cancer Care Inc. 327 Renfrew Street Updated July 2011 Dr. Walter Lemmo, ND is a licensed naturopathic physician registered with the Col ege of Naturopathic Physicians of British Columbia. He provides his services through Lemmo Integrated Cancer Care Inc., a legal entity incorporated in the Province of British Columbia. Consultations
Follow-up consultations (about 30 to 60 minutes): Extended Health Plans
Extended health insurance, where applicable, may cover al or a portion for the fees. At the end of each visit, you wil be given a sales receipt to submit to your extended health insurance carrier. Most extended health insurance plans offered by large corporations wil have some coverage for naturopathic services. Please check with your particular carrier for its policies on coverage. Other Costs
All tests, treatments and remedies are not covered by MSP (costs wil vary). A 24-hour notice is required for
cancellations or you wil be bil ed $30.00 for each missed visit. NSF Cheques are charged at $20.00 as a processing fee
charged for each NSF cheque. The clinic reserves the right to change fees at any time. Please contact the clinic directly by
phone or email to receive the latest information.
Research
There may be noteworthy findings, treatment results or outcomes that occur under the supervision of Dr. Lemmo, which
could benefit future patients and the scientific research community if they are made aware. By being a patient of Dr. Lemmo,
you are asked to provide consent for Dr. Lemmo to potential y use certain aspects of your medical data for scientific research
and the potential publication of such research. In any event, your personal information, such as your name, address,
and telephone number, would be kept strictly confidential as part of standard medical research guidelines.
By signing the bottom of this policy, you are indicating that you have read and understood the above statements and agree to
pay upon receiving the products and services as outlined.
PATIENT’S FULL NAME
SIGNATURE
DATE SIGNED (MM/DD/YY)
Dr. Walter Lemmo, ND, FABNO Lemmo Integrated Cancer Care Inc. 327 Renfrew Street RECORDS RELEASE FORM
TO (PHYSICIAN OR MEDICAL CENTRE)
Could you please release the records of patient (print name)______________________________to the above address or fax number of Dr. Lemmo. Patient Information
FULL NAME
DATE OF BIRTH (MM/DD/YY)
PERSONAL HEALTH NUMBER (PHN)
COMPLETE RECORDS
RECENT RECORDS
DURING THE LAST (PLEASE CIRCLE) 1, 2, 3, 4, 5, 6 MONTHS WBC/ICBC REPORTS
X-RAY/ULTRASOUND
MRI/CT-SCAN/PET-SCAN
LABORATORY
PATIENT SIGNATURE
PHYSICIAN SIGNATURE
DATE SIGNED (MM/DD/YY)
DATE SIGNED (MM/DD/YY)

Source: http://www.lemmo.com/LEMMO-Intake-Form.pdf