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1 Box 1570, nd Ave West Brooks, AB T1R 1C4 Ph: Fax: Dear Patient, Thank you for choosing Soft Health and Healing Clinic as your health care provider for your Worker s Compensation Board (WCB) claim. We look forward to providing you with top notch, state-of-the-art care. There are a few things you must accomplish before beginning treatment at Soft Health and Healing Clinic: 1. You must report the injury as soon as possible to your employer. He/she will send an Employer Report of Injury form to WCB within 72 hours. 2. You must also see your family physician regarding your injury. He/she will complete a Physician s Injury Report and send it to WCB within 48 hours. 3. Complete a Worker s Report of Injury if you have a permanent injury, need medical treatment or are off work. Send your report to the WCB. WCB will register your compensation benefits upon receiving all of these reports. You will then have a representative assigned to your claim. Please make sure that the information you provide is as detailed and complete as possible as this will help for a timely decision on your claim. In order to receive treatment at Soft Health and Healing Clinic you will be required to sign a WCB contract explaining that you are responsible for the costs of your treatments should the WCB deny your claim. Coverage through WCB entitles you to one treatment per day, up to a twenty-two (22) treatment maximum, over a 6 week period. A soft tissue session counts as one (1) treatment, and a low intensity laser therapy session also counts as one (1) treatment. We will contact the WCB requesting more care if the Doctor feels it is necessary. Please read through the information provided and fill out all attached questionnaires. Remember that the more information we have, the better we can diagnose and treat your condition. Please make sure to note anything you have noticed leading up to and/or after the injury, no matter how insignificant it may seem. Yours in Health, Soft Health and Healing Clinic
2 Worker s Compensation Board Intake Forms Personal Information: First Name Middle Initial Last Name Alberta Health Care # Date of Birth Male / Female Address City Province Postal Code Ph# (home) Ph# (work) Ph# (cell) WCB Claim # Claims Rep. Name Ph# Work information: Job Title: Employer Name: Company Ph: ( ) Ext. Address: City: Province: Postal Code: Injury Information: Date of Injury (YYYY/MM/DD): Date of First Treatment (YYYY/MM/DD): Describe, fully, what you believe caused your condition. Please include any relevant past history. Area(s) of Injury/Disease: O Ankle O Arm O Back O Brain O Elbow O Face O Fingers O Foot O Hand O Head O Knee O Leg O Non-personal O Shoulder O Systems O Teeth O Trunk O Unknown O Wrist Side of the Body: O Right O Left O Both Sides Have you had the same or similar complaint before? O Never O 2 times O 4 times O Multiple times O 1 time O 3 times O > 4 times Has the problem been getting better or worse since the onset? O Improving O Getting worse O Comes and goes O Stayed about the same What limitations have you experienced as a result of your injury? (choose all that apply and circle capabilities) O Sitting Able Unable Limited to O Climbing Able Unable Limited to O Standing Able Unable Limited to O Pushing/Pulling Able Unable Limited to O Walking Able Unable Limited to O Overhead reaching Able Unable Limited to O Bending Able Unable Limited to O Driving Able Unable Limited to O Twisting Able Unable Limited to O Lifting Able Unable Limited to O Kneeling/squatting Able Unable Limited to
3 Describe how this injury affects your job requirements: Have you missed any work as a result of your condition? O Yes - If yes, how many days did you miss? days. O No Have you returned to work? O Yes O No Current work status: O Yes full duties O Yes modified duties O Yes alternate duties O No not working at all Is modified work available? O Yes it is available and I can perform the required tasks O Yes it is available but I cannot perform the required tasks O No it is not available/possible Are you working Modified hours? O Yes O No If not working do you have a job to return to? O Yes O No Your last full day of work was (YYYY/MM/DD)? Are you currently receiving worker s compensation? O Yes O No List your surgical and hospitalisation history. Past Surgical History Date: Where: Type of Surgery: Surgeon: Complications/remaining problems: Past Hospitalisations Date: Cause of Hospitalisation: Complications/remaining problems: List your previous medical treatment and diagnostic tests. For example: Plain X-rays / CT Scan / MRI / EMG / Myelogram / Discogram / Thermogram / Bone Scan / Blood & Urine Chemistries / Other Type of Test: Date (approx): Hospital/facility name: Area of Body: List your current medications, both prescription and non-prescription:
4 Health History Questionnaire Have you ever been diagnosed or told you have any of the following: Circle the correct response. 1. High Blood Pressure? Yes/No 2. Hardening of the arteries (arteriosclerosis)? Yes/No 3. Diabetes? Yes/No 4. Tuberculosis? Yes/No 5. Cancer? Yes/No 6. Heart or blood diseases? Yes/No 7. Bone spurs on the neck? Yes/No 8. Whiplash injury? Yes/No 9. Have you or any of your relatives ever suffered a stroke? Yes/No 10. Were you ever a Smoker? Yes/No From To 11. Do you take medication on a regular basis? Yes/No 12. Visual disturbances (blurring, loss, double vision)? Yes/No 13. Hearing disturbances (loss, ringing, other noise)? Yes/No 14. Slurred speech or other speech problems? Yes/No 15. Difficulty swallowing? Yes/No 16. Dizziness? Yes/No 17. Loss of consciousness, even momentary blackouts? Yes/No 18. Numbness, loss of sensation, loss of strength or weakness in the face, fingers, hands, arms, legs, or any other parts of the body? Yes/No 19. Sudden collapse without loss of consciousness? Yes/No 20. Back pain/leg Pain Yes/No 21. Neck pain/arm Pain Yes/No 22. Depression, Anxiety, etc. Yes/No 23. Recent international travel Yes/No Please explain any Yes answers above:
5 Systems Review Circle any conditions that are presently causing you a problem. Underline those that have caused you problems in the past. GENERAL SYMPTOMS RESPIRATORY GENITOURINARY Fever Sweats Fainting Sleep disturbance Fatigue Nervousness Weight loss Weight gain Chronic cough Spitting up phlegm Spitting up blood Chest pain Wheezing Difficulty breathing Asthma Frequent urination Painful urination Blood in urine Pus in urine Kidney infection Prostate trouble Uncontrollable urine flow NEUROLOGICAL CARDIOVASCULAR GASTROINTESTINAL Visual disturbance Dizziness Fainting Convulsions Headache Numbness Neuralgia (nerve pain) Poor coordination Weakness Rapid beating heart Slow beating heart High blood pressure Low blood pressure Pain over heart Hardening of arteries Swollen ankles Poor circulation Palpitations Cold hand or feet Varicose veins Poor appetite Difficult digestion Heartburn Ulcers Nausea Vomiting Constipation Diarrhea Blood in stool Gallbladder/jaundice Colitis EYES, EARS, NOSE, THROAT MUSCLE & JOINT FOR WOMEN ONLY Eye pain Double vision Ringing in ears Deafness Nosebleeds Trouble swallowing Hoarseness Sinus infection Nasal drainage Enlarged glands Neck pain Low back pain Arm pain Shoulder pain Leg pain Knee pain Foot pain Pain/numbness down arms or legs Pain between shoulders swollen joints Spinal curvature Arthritis Fractures Painful menstruation Hot flashes Irregular cycle Cramps or back pain Vaginal discharge Nipple discharge Lumps in breast Menopausal symptoms Birth control pills Miscarriages Complications with pregnancy Pregnant? Y / N Week? Other:
6 Pain Drawing
7 Activities Discomfort Scale
8 Box 1570, nd Ave West Brooks, AB T1R 1C4 Ph: Fax: _ Worker s Compensation Board Contractual Agreement 1. I understand that Soft Health and Healing Clinic has agreed to provide chiropractic services and will not require payment until my claim has been approved by WCB, after which time Soft Health and Healing Clinic will bill WCB directly. 2. I understand that if I am not approved by the WCB, that I am liable for any and all charges incurred for services provided to me by Soft Health and Healing Clinic 3. In the event that the WCB denies my approval after already having approved it, I understand that I will be responsible for payment of fees from the date of denial forward. 4. I understand that Soft Health and Healing Clinic has a cancellation policy in place, wherein any appointment missed or cancelled within 24 hours is subject to a cancellation fee equal to the treatment fee. I further understand that I, not WCB, am responsible for payment of any cancellation fees. 5. I understand that if I cancel or fail to show up for three consecutive appointments (without explanation within twenty four [24] hours) that Soft Health and Healing Clinic will automatically suspend my treatments and notify my case worker. Soft Health and Healing Clinic will not arrange extra treatments to make up for such absences. 6. I understand that my initial treatment protocol period is six (6) consecutive calendar weeks with a maximum of twenty two (22) treatments available and that only one (1) treatment can be performed and billed to WCB per day. Patient Name (Printed) Patient Signature Date Witness to Above Signature Visa MC Amex Credit Card # Expiry
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11 Cancellation Policy Purpose The purpose of this policy is to encourage awareness that missed appointments have an impact on the physician s, therapists and patients schedules. Arranging appointments according to prescribed treatment plans assists both patient and practitioner in achieving optimal healing goals in a quicker timeframe. Policy Soft Health and Healing Clinic requires 24 hours notice if an appointment is to be missed. Less than 24 hours notice will result in a cancellation fee of $40. Thank you for your understanding. THE 50% RULE The chiropractic physician is seeking 50% relief of pain (measured subjectively and objectively) within 30 days of care. TYPICAL PATIENT OUTCOMES Median number of days to maximum improvement: 29 Median number of visits to maximum improvement: 12
12 OFFICE USE ONLY Claim #: AHC#: Adjustor s Name: Adjustor s Phone#: Date of Injury: Exam Date: Chiropractic First Report Submission Date: Progress Report Date: Treatment Extension Request Date: Discharge Date: Notes:
CONSULTATION ADMITTANCE FORM
CONSULTATION ADMITTANCE FORM Last Name: First Name: Address: City Postal Code: Home Phone: Work Phone: Age: Birth date (dd/mm/yr): Sex: M / F Height Weight Occupation: Alberta Health Care #: PLEASE CHECK
ACTIVE EDGE CHIROPRACTIC
ACTIVE EDGE CHIROPRACTIC HEALTH HISTORY QUESTIONNAIRE PERSONAL INFORMATION Name: Female Male Alberta Health Care# Address: City: Province: Postal Code: Telephone: Home: Work: Cell: Email: Occupation: Birth
Child History Form. Personal Information. Legal Guardian & Occupation: Home Phone: Alternate Phone: Provincial Health Care Plan
Child History Form (Ages 6-12) The data on this form is essential if we are to render the best professional care. We appreciate your cooperation in filling it out so that we will have accurate records.
CHIROPRACTIC ASSOCIATES CLINIC
CHIROPRACTIC ASSOCIATES CLINIC 1127 LAKEWOOD COURT NORTH, REGINA, SK S4X 3S3 PH: (306) 924-5300 FAX: (306) 924-5252 EMAIL: cac.north@accesscomm.ca CHIROPRACTIC INITIAL HEALTH FORM PATIENT INFORMATION Last
Reason forappointment:
Patient Information Date / / Patient Name (last, first) Sex: Male / Female Home Phone # ( ) Cell Phone # ( ) E-Mail Address Address City State Zip Code Date of Birth / / Age Occupation Who Referred You
PATIENT INTRODUCTION
PATIENT INTRODUCTION Personal History: Mr. Mrs. Miss Ms. Dr. Name: First Middle Last Your Address: _ City: Prov: Postal Code: Telephone: Home: Bus: Cell: E-Mail: Check this box if we may contact you via
CHIROPRACTIC ASSOCIATES CLINIC
CHIROPRACTIC ASSOCIATES CLINIC 1127 LAKEWOOD COURT NORTH, REGINA, SK S4X 3S3 PH: (306) 924-5300 FAX: (306) 924-5252 EMAIL: cac.north@accesscomm.ca CHIROPRACTIC INITIAL HEALTH FORM Which Chiropractor are
Johanna M. Hoeller, DC PS
ENTRANCE FORM Birth date: Height: Weight: Emergency Contact: Emergency Contact Phone: ( ) Spouse/Partner or Parent s name: Children s names: Occupation (Your): Employer: Address: City/State/Zip: Phone:
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Email Address: Emergency Contact Name and Phone Number: Family Doctor Name and Address:
CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.
WELCOME TO THE BURLINGTON NATURAL HEALTH CENTRE PLEASE FILL IN THESE FORMS AS COMPLETELY AS POSSIBLE. THANKYOU!
WELCOME TO THE BURLINGTON NATURAL HEALTH CENTRE PLEASE FILL IN THESE FORMS AS COMPLETELY AS POSSIBLE. THANKYOU! NAME DATE ADDRESS Gender CITY, PROVINCE HOME PHONE E MAIL POSTAL CODE DATE OF BIRTH (D/M/Y)
Patient Introduction
Date: Patient Introduction Name: First Middle Last Birth Date: Month: Day: Year: Age: Gender: Male Female Address: PC: Telephone: Home: Cell: Work: Emergency contact name and #: Alberta Health Care Number:
Patient Name (last, first) Sex: Male / Female
Patient Information Date / / Patient Name (last, first) Sex: Male / Female Home Phone # ( ) Cell Phone # ( ) E-Mail Address Address City State Zip Code Date of Birth / / Age Occupation Who Referred You
CONSULTATION ADMITTANCE FORM
CONSULTATION ADMITTANCE FORM Last Name: _ First Name: Sex: M / F Address: City Postal Code: Home Phone: Work Phone: Cell Phone: Cell Phone Provider: E-mail: Occupation: Marital Status: No. of children:
Home Address. City Postal Code Home Telephone # Business Telephone # Address. Emergency Contact Name, Address, Phone#
Date Name / / last first middle initial Personal Health # - Male Female Home Address City Postal Code Home Telephone # Business Telephone # Cell # E-Mail Address Best way to contact you: Home # Work #
Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION
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INFORMATION/APPLICATION FOR CARE
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KEY TO LIFE CHIROPRACTIC
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Street address: City: State: Zip: Address:
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New Patient Information
Personal Information Last Name First Name Middle Initial Address: Street Unit # City Province Postal Code Date of Birth (Day/Month/Year) Home Phone # Work Phone # Cell Phone # May the clinic leave you
Today s Date: What are your health goals? Symptom relief and preventing its return 100% optimum health and wellbeing on every level available to me
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AHI - New Patient Information
Personal Information Last Name First Name Middle Initial Address: Street Unit # City Province Postal Code Date of Birth (Day/Month/Year) Home Phone # Work Phone # Cell Phone # May the clinic leave you