Gait Analysis Client Intake Form
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- Ralph Horn
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1 Gait Analysis Client Intake Form Date: / / Welcome to the clinic! Please complete the following questionnaire. Your answers will help us better analyze your gait data. PERSONAL INFORMATION Name :_ last first middle initial Age: Weight: Height: Male Female Home Address: Phone (H): Phone (C): Birth Date / / Marital Status: M S W D Address How did you first find out our gait analysis service? Have you had a gait analysis test before? Yes No What do you hope to gain from this assessment? (Goals?) Page1
2 HEALTH INFORMATION 1. In your own words, please describe your chief complaint and when you first noticed the problem. (if you currently have an injury or an area of soreness/stiffness) 2. What seems to make the problem better? 3. What seems to make the problem worse? 4. What type of pain is it? (Please check) Sharp Stabbing Achy Burning Dull Diffuse Localized 5. Does the pain radiate? Yes No 6. At what time of the day does it seem to be at its worst? 7. Has this problem ever been treated before? If so, with what therapy? PHYSICAL HISTORY Please circle any conditions you have or have had in the past Musculoskeletal system Specific Injuries Neck problems Patellofemoral pain syndrome Muscle tear/strain Upper back problems Achilles tendonitis (tendonosis) Foot stress fracture Tendonitis: location(s): Arthritis: location(s): Shoulder problems Illiotibial band friction syndrome Elbow/wrist problems Plantar faciitis Low back problems Shin splints Hip/pelvis problems Compartment syndrome Knee problems Meniscal injury Lower leg problems Tibial stress fracture Ankle/foot problems Other: Additional Notes: Page2
3 ACTIVITY INFORMATION 1. What physical activities do you currently participate in? 2. Please describe your typical weekly training/activity routine: NOTE: If you have recently been off due to injury please describe your routine pre-injury Sunday Monday Tuesday Wednesday Thursday Friday Saturday 3. Estimated average weekly walking and/or running mileage: 4. Estimated hours of Running/walking per week: 5. Please describe your typical running terrain (e.g. road, track, trail, grass): 6. Please describe your level of competition: Recreational Provincial National International Please use the space below to provide any other information you feel might be important. Page3
4 Informed Consent for Examination and Treatment You should be in good physical condition and be able to participate in this analysis. By engaging in this testing or exercise program, you agree that you do so at your own risk, are voluntarily participating in these activities, assume all risk of injury to yourself, and agree to release and discharge Pursuit Athletic Performance, LLC from any and all claims or causes of action, known or unknown, arising out of their negligence. In signing this waiver, you agree that you are unaware of any medical condition that would prevent you from participating in the analysis procedures and proposed exercise program, or have documented clearance from a physician to participate. I (we) hereby consent to the performance of examination and treatment of myself or of the undersigned by the licensed doctors of chiropractic, physical therapists and/or licensed massage therapists who may be employed or engaged in practice in this clinic. I have had an opportunity to discuss with the doctor(s) or other clinic personnel the nature and purpose of the different physical/massage therapy procedures and chiropractic treatments (manipulation/adjustment). I understand that neither chiropractic nor medical treatment is an exact science and that my care may involve judgments based on facts and information known to the doctor. The doctor uses this judgment to attempt to anticipate or explain risks and complications, and an undesirable result does not necessarily indicate an error in judgment. No guarantee for results can be made or expected, but rather I wish to rely on the doctor to choose and recommend a best course of treatment, based upon facts known, that is in my best interests. I further understand that there are certain degrees of risk associated with chiropractic health care, massage therapy and physical therapy, which includes rarely, but not limited to fractures, disk injuries, strokes, and strains/sprains. I am willing to accept and consent to the risk associated with the care that I am about to receive. I have read, or the above information has been explained regarding consent. I have had an opportunity to ask questions about my examination and treatment. By signing below, I agree and intend this consent form to cover the procedures prescribed for my condition and for any future conditions for which I seek treatment. Female patients: By my signature on this form I do hereby state that to the best of my knowledge I am not pregnant, nor is pregnancy suspected or confirmed at this particular time. Date of last menstrual period. I acknowledge that I have received a Notice of Privacy Practices and I have been provided an opportunity to review it. Further, I understand that I must give 12 hours notice for cancellation of appointments and that failure to do so may result in a $25 charge. I understand and agree that insurance policies are arrangements between insurance carriers and me. I acknowledge that all services rendered and charged to me are my personal responsibility. Please choose one by initialing: I grant Pursuit Athletic Performance, LLC permission to use video and/or photographs of myself for advertising, website or other purposes. I DO NOT grant Pursuit Athletic Performance, LLC permission to use video and/or photographs of myself for advertising, website or other purposes. PRINT NAME PRINT NAME of Guardian if under 18 SIGNATURE SIGNATURE of Guardian Page4
5 What to bring to your gait analysis appointment: 1. Current running or walking shoes 2. Previous pair of running or walking shoes if your current pair is brand new (or any other past shoes that you have questions on) 3. Current pair of orthotics if you have them 4. Shorts - as short or form fitting as possible 5. A t-shirt, tank top or sports bra (if you feel comfortable wearing this for the analysis) as form fitting as possible, not black if possible 6. A pair of comfortable socks 7. A hair elastic if you have long hair 8. A list of any questions/concerns you might want to have answered Note: Please avoid putting moisturizers on your legs/arms the day of your assessment as markers may be placed or drawn on your skin to enhance visibility. Page5
Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No
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Family First Chiropractic Personal Information Title: (Check one) Mr. Mrs. Ms. Miss Other First Name Middle Initial Last Name Street City State Zip Code Email Home Phone ( ) - Cell Phone ( ) - Date of
Hamilton Back Clinic
Hamilton Back Clinic Intake Form Name: City: Address: Postal Code: Phone: Sex: M F Date of Birth: Month/Day/Year E mail: Emergency Contact: Name/Phone: Name of Family Physician (MD): Employer: Employer
Family First Chiropractic
Personal Information Title: (Check one) Mr. Mrs. Ms. Miss Other First Name Middle Initial Last Name Street City State Zip Code Email Home Phone ( ) - Cell Phone ( ) - Date of Birth / / Sex: Male Female
It's your life... be there healthy. RIGHT LEFT RIGHT
Dr. Sara Weigel Dr. Douglas Ness Active Life It's your life... be there healthy. Chiropractic Patient Information Major Complaint Information Date First Name: Last Name: Initial What is your major complaint(s)?
City State Zip. Home Phone Mobile Phone. Can we text you appointment reminders? Yes / No If yes, who is your wireless carrier?
CryoBoost Lubbock 5206 82 nd St., Suite 15 (inside Austin Chiropractic) CryoBoost Allen 801 S Greenville Ave., Suite 115 (inside Wellness) Physical Readiness Questionnaire Name Date Address City State
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
Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac Brant Street, Burlington, Ontario L7R 2J9 (905) Fax (905)
Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac. Personal History: Name: Address: City: Province: Postal Code: Birth date: day /month /year Age: Sex: M F Home Phone: Business Phone: Cell Phone: E-mail: Health
Patient First Name: Last Name: Street Address: City: State: Zip Code. Mobile Phone: Home Phone: Work Phone:
Dr. Beth Kozak Welcome! New Patient Information Form Please provide us with the following information: Patient First Name: Last Name: Street Address: City: State: Zip Code Mobile Phone: Home Phone: Work