Executive Health at Paradise Fields

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executivehealth@paradisehealth.ca
289-763-5994

Full NameEmail AddressResidential addressPhone numberDate of birthSexOHIP #Insurance / health benefits providerInsurance plan member full name, date of birth and relationship to patient (if different)Insurance group/plan numberInsurance certificate/member ID numberCurrent weight (in lbs)Current height (in cm)Primary health concern(s)Medical historyCurrent medications or supplementsDid your parents have any health concerns?What are your health goals?Dietary patternNumber of bowel movements per dayUsual urine colorNumber of meals per dayDo you snack?Largest meal of the dayLast meal of the day is at ...I eat dairy productsI eat meatI eat nuts and seeds dailyI eat fruits and vegetables dailyI drink coffee, tea or other caffeinated beveragesI consume alcoholDo you smoke or vape?Usual bedtimeTypical stress levelsHow many days per week do you engage in moderate to high intensity aerobic physical activity?How many days per week do you engage in strength training physical activity?How many days per week do you get at least 20 minutes of sunshine?How many days per week do you spend time in nature?Marital statusDo you have children?I have strong social connections with 2 or more friendsSpiritual practices (select all that apply)Anything else you would like to share about your health or health goals?Billing: I understand and accept that my OHIP number will be used to bill OHIP for the consult with the medical doctor.

Waiver: I agree to waive any claim for damages of any nature whatsoever and to release Paradise Health Clinic, and Paradise Fields, and each of their respective subsidiaries, affiliates, officers, directors, employees, volunteers and agents from any liability or responsibility whatsoever for any ill-effect, injury, or loss incurred by the guest or any third party including, but not limited to, all manner of actions, causes of action, suits, debts, damages, claims, demands, costs, losses and expenses of any type or kind whatsoever, arising from, connected with or related to the consumption of food, and the availing of services. Indemnification: I agree to indemnify, defend and hold harmless Paradise Health Clinic, and Paradise Fields, and each of their subsidiaries, affiliates, officers, directors, employees, volunteers and agents from and against all liability, claims, actions, causes of action, suits, demands, damages, judgments, costs, losses and expenses, including reasonable attorney’s fees, to which any of the above-named parties may be subject, including, but not limited to, any claim for any injury to or the sickness or death of any person or persons, or for damages to property or otherwise, arising from, connected with or related to the consumption of food, and the availing of services.Informed consent:

This executive health program utilizes the principles of Naturopathic, Nutrition, Massage Therapy and Lifestyle Medicine to promote health. The program's components will include:
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• Body composition analysis
• Vitals (blood pressure, waist circumference, height, pulse, temperature)
• Physical exams (example auscultation of the heart to assess cardiovascular conditions)
• VO2 max (progressive treadmill test to maximal exertion to assess cardiorespiratory fitness)
• Musculoskeletal fitness assessment (grip strength, push ups, sit and reach, vertical jump, back fitness and balance assessments
• Blood test prior to arrival
• Consults with the following clinicians: medical doctor, naturopathic doctor, exercise physiologist, registered massage therapist and nutritionist
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The slight health risks of some of the assessments include, but are not limited to: aggravation of pre-existing symptoms or conditions, allergic reaction to supplements or herbs and pain.

I understand that while naturopathic medicine, lifestyle medicine, nutritional therapies and massage therapy are very gentle therapies, even these may induce complications in certain physiological conditions such as pregnancy, lactation, very young children, very elderly and in certain conditions including but not limited to diabetes, liver, heart or kidney disease. It is therefore important to inform your clinicians of any illnesses you suffer from or medications you may be taking (prescription or over-the- counter). If you are a female and are pregnant, suspect you may be pregnant or are nursing, please advise your clinician immediately.

Consent

As a patient of the executive health program and Paradise Health Clinic:

• I am at liberty to seek or continue medical care from a medical doctor or other health care provider.
• This consent form is intended to cover the entire course of the program for my present condition.
• I understand that I am free to withdraw my consent and to discontinue participation at any time.
• I understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others without my consent, unless required by law.
• I understand that I may look at my medical record at any time and may request a copy of it by paying the appropriate fee.
• I understand that the clinicians will answer any questions I have to the best of their ability.
• I understand that the results are not guaranteed.
• I understand that the Medical Doctor and is not a replacement for my primary care provider / family physician. I understand that if I request health records (including labs) to be sent to my primary care family physician, this can be arranged. This also applies to the other healthcare providers unless special arrangements are made for continued care after the program. I understand that any follow-up appointments with the licensed naturopathic doctor(s), registered massage therapists or certified nutritionists are done so independently and any fees for service are not covered by the registration price for this program.

With this knowledge I voluntarily agree to the assessments described above.

Photo and video release an consent: I understand and accept that photos and videos may be taken during public components of the program, but not private components unless with my direct consent. Public components may include, but not limited to, the registration/check-in area, external signage and building, sampling and literature table. Private components include during individual consults and assessments.

I understand and accept that I may appear in these photo and videos and that Paradise Health Clinic and Paradise Fields may use these photos and videos in electronic communication, websites and social media.

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Executive Health at Paradise Fields

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