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18 Crown Steel Drive Suite 308, buz code 3080 Markham, Ontario L3R 9X8

(905) 294-1990rlmcd@rogers.com

The Robert McDonald Clinic

Traditional Chinese Medicine

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About Us
The Pillars
Therapies
Contact

New Patient Intake Form

INTAKE FORM - NEW PATIENT

Name(Required)

First Last

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Mobile(Required)

Date of Birth(Required)

Occupation

Email(Required)

Reason for seeking Treatment?(Required)

Past Medical History

Have you or any of your immediate family member ever been told you have

Cancer(Required)

Yes

No

Myself

Family

N/A

Diabetes(Required)

Yes

No

Myself

Family

N/A

Hypoglycemia (low blood sugar)(Required)

Yes

No

Myself

Family

N/A

Hypertension (high blood pressure)(Required)

Yes

No

Myself

Family

N/A

Heart disease(Required)

Yes

No

Myself

Family

N/A

Angina(Required)

Yes

No

Myself

Family

N/A

Stroke(Required)

Yes

No

Myself

Family

N/A

Shortness of breath(Required)

Yes

No

Myself

Family

N/A

Kidney disease / stones(Required)

Yes

No

Myself

Family

N/A

Urinary tract infection(Required)

Yes

No

Myself

Family

N/A

Asthma(Required)

Yes

No

Myself

Family

N/A

Hay fever(Required)

Yes

No

Myself

Family

N/A

Rheumatic / Scarlet fever(Required)

Yes

No

Myself

Family

N/A

Hepatitis / Jaundice(Required)

Yes

No

Myself

Family

N/A

Polio(Required)

Yes

No

Myself

Family

N/A

Cirrhosis / Liver disease(Required)

Yes

No

Myself

Family

N/A

Chronic bronchitis(Required)

Yes

No

Myself

Family

N/A

Pneumonia(Required)

Yes

No

Myself

Family

N/A

Emphysema(Required)

Yes

No

Myself

Family

N/A

Migraine headaches(Required)

Yes

No

Myself

Family

N/A

Tuberculosis(Required)

Yes

No

Myself

Family

N/A

Anemia(Required)

Yes

No

Myself

Family

N/A

Ulcers / Stomach problems(Required)

Yes

No

Myself

Family

N/A

Depression(Required)

Yes

No

Myself

Family

N/A

Anxiety(Required)

Yes

No

Myself

Family

N/A

Chemical Dependency (alcohol/drugs)(Required)

Yes

No

Myself

Family

N/A

Arthritis(Required)

Yes

No

Myself

Family

N/A

Gout(Required)

Yes

No

Myself

Family

N/A

Hemophilia(Required)

Yes

No

Myself

Family

N/A

Slow Healing(Required)

Yes

No

Myself

Family

N/A

Epilepsy(Required)

Yes

No

Myself

Family

N/A

Multiple Sclerosis(Required)

Yes

No

Myself

Family

N/A

Thyroid problems(Required)

Yes

No

Myself

Family

N/A

Fibromyalgia(Required)

Yes

No

Myself

Family

N/A

Other

General Health

What medications are you taking? Please list both prescription and over the counter medications(Required)

Have you had any illness within the last 3 weeks? (e.g. colds, flu’s , infections)(Required)

Yes

No

If Yes, please explain

Do you smoke or chew tobacco?(Required)

Yes

No

How much alcohol do you drink in the course of a week?(Required)

Do you use recreational drugs? If yes, what, how much and how often?(Required)

How much caffeine do you consume daily? (including soft drinks, coffee, tea and chocolate)(Required)

Do you have a pacemaker, organ transplant, joint replacements, or metal implants?

Have you had any medical tests done recently? (i.e. X-rays, CT scans, MRI’s, ultrasounds, bone scan etc..)

Have you had any lab work done? If so do you know the results?

What surgery have you had done in your life? Please list the year it was done as well.

Please list any allergies that you have

What is your history of injury? (i.e. car accidents, slip and fall, sports injury, etc.)

Consent(Required)

I agree to the Clinic policy.

We require 24-hour notice for cancellation of your appointment. Missed appointments or last minute cancellation will be charged a full fee.
I have filled out the above New Patient Intake form to the best of my knowledge and I have read the clinic policy

Your Full Name(Required)

Today's Date(Required)

Δ

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THE PILLARS

Pillar 1: Structural Integrity (The Hardware)
Pillar 2: Fluid Dynamics (The Clearance System)
Pillar 3: Neurological Communication (The Software)
Pillar 4: Cellular Regeneration (The Power Source)

CONTACT DETAILS

18 Crown Steel Drive Suite 308, buz code 3080 Markham, Ontario L3R 9X8
Phone: (905) 294-1990
Fax: (905) 947-1705
Email: rlmcd@rogers.com

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