Welcome to our clinic! NEW PATIENT HEALTH QUESTIONNAIRE

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1 Welcome to our clinic! NEW PATIENT HEALTH QUESTIONNAIRE First Name: Last Name: Date of Birth (mm/dd/yyyy): / / Gender: Male Female Current Occupation: Address: Appt no. Postal Code: Home Phone ( ) - Work Phone ( ) - Cell Phone ( ) - How would you like us to contact you? By By Telephone Emergency contact: Relationship to you: Phone: ( )- For our own data collection purposes, how did you hear about us? Website Family doctor Google search One of our health care provider Word of mouth by another patient Law firm (name: ) Walk-in / I live near the clinic Advertisement Conference/Seminar Other (specify: ) Medical Doctor Information: Our talented health care providers work closely with your medical doctor to ensure that he/she is aware of your ongoing progress. Please, document the following: Name of your medical doctor: Address of the medical clinic: Clinic s Telephone: ( ) - Approximate date of your last physical examination: OHIP number (for X-Ray referrals, if justified): Do you give us permission to contact your medical doctor to provide him/her with documentation regarding your case? NO YES What is the purpose of your visit? Consultation only Pain Relief Preventative Care Functional Rehabilitation Athletic Care Pregnancy Care Got in a car accident WSIB claim Do you have private insurance benefits for: Chiropractic Physiotherapy Chiropody Orthotics I don t have insurance Our physiotherapists and chiropractors can provide a computerized feet screen (at no charge) for our ongoing patients only to help them understand how erroneous their walking patterns and feet anatomy can impact their functionality. Would you be interested? YES NO

2 Are you currently on any prescription medication? YES NO If yes what are these medications?

3 Medical Information For your safety, we need information about your medical history. Please answer to the best of your knowledge: Are you or did you experience one or more of the following: SKIN Rashes Skin infection Psoriasis MUSCLES Pain in the: Neck Midback Low back Shoulder Elbow Arm Wrist Hand Hip Leg Knee Ankle Foot Loss of strength Clumsiness Osteoporosis (poor bone density) Osteoarthritis Rheumatism Other arthritis (list below): Tendonitis where: Strain where: Dislocation where: NOW PAST NOW PAST NOW PAST Shortness of breath. Stress Smoking Nausea Other (please list) Vomiting CARDIOVASCULAR Bleeding disorder High blood pressure High Cholesterol Diabetes Low blood pressure Heart Attack Stroke Angina Pacemaker Varicose Veins Phlebitis Poor circulation Other (please list) HEAD NECK Visual changes Hearing changes Speech changes Headaches Jaw Pain Sinus problems BOWEL Constipation Diarrhea Crohn s Disease Hiatus Hernia Ulcers Appendicitis INFECTION Hepatitis (type: ) HIV Tuberculosis Recent flu Recent cold Please CIRCLE what is applicable to your case: FRACTURES NONE YES If yes when and where? SURGERY NONE YES IF yes when and where? CAR ACCIDENTS Other injury (list below): LUNGS Asthma Bronchitis Chronic cough Difficulty breathing Emphysema OTHERS Allergies Cancer Fainting Fever Insomnia Numbness / tingling Seizures How many car accidents you had so far? Is this a new car accident? (circle) YES or NO

4 IMPORTANT By the law, Canada s new Anti-Spam Legislation (CASL) requires that we obtain your consent as of July 1 st, 2014 in order for you to continue receiving electronic communications from us. We would not want you to miss out on any information that is beneficial to you. First Name: Last Name: Please check which of the following you would like to stay informed about. Appointment Reminders/ Confirmations Clinic Newsletter Kinesiology Information Focus Group News/ Information Clinic Seminars Acupuncture Information Orthotics Information Twitter Updates/Invites Facebook notifications I do NOT want to receive any s You may withdraw your consent or modify your subscription preferences at any time. Signature:

5 Our Fees Kent Chiro-Med Wellness Clinic Health Services FEES ($ CAN) CHIROPRACTIC FEES Initial Examination Subsequent Regular Chiropractic Treatment (per visit) ADULTS FULL-TIME STUDENT* (23 and under) Subsequent Graston Treatment only (per visit) Combination: Graston + Chiropractic Treatment (per visit) Combination: Acupuncture + Chiropractic Treatment (per visit) Subsequent Acupuncture Treatment (per visit) ADULTS FULL-TIME STUDENT (23 and under) Subsequent Shockwave Therapy (options: 1000 shocks or 2000 shocks) (per visit) / Subsequent Spinal Decompression (per visit) PHYSIOTHERAPY SERVICES Initial Examination Subsequent Regular Physiotherapy Treatment (per visit) ADULTS FULL-TIME STUDENT (23 and under) OTHER SERVICES Kinesiotape (per one area of application during a treatment) Kinesiotape (per roll) Biofreeze (each) Electrical Modalities (Ultrasound / IFC machine) (per application) Thumper quick massage (15 minutes) X-Ray Report Exercise prescription (per visit) TENS machine (for home use) 250 Ergonomic water-based pillow (for home use) 100 Custom-made Orthotics 500 *Students must present valid student ID prior to initial appointment visit. As a courtesy to all our patients, we ask that you give 24 HOUR notice for cancellation of any appointment. Failure to do so will result in a $25.00 cancellation fee. I am fully aware of the fees and am informed about them in advance. (Signature: ).

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