Cascadia Chiropractic Centre

Similar documents
Cascadia Chiropractic Centre

Brisbin Family Chiropractic

PATIENT ENTRANCE FORM

CHIROPRACTIC NEW PATIENT FORM REASON FOR VISIT

Extended Health Care Company Do you need any help retaining information about your health insurance coverage? Yes No

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

CHIROPRACTIC NEW PATIENT FORM REASON FOR VISIT

CHIROPRACTIC NEW PATIENT FORM REASON FOR VISIT

Adult Health Questionnaire

CONSULTATION ADMITTANCE FORM

Home Address. City Postal Code Home Telephone # Business Telephone # Address. Emergency Contact Name, Address, Phone#

WELCOME TO THE MILLER CHIROPRACTIC CLINIC

History of Present Condition

Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac Brant Street, Burlington, Ontario L7R 2J9 (905) Fax (905)

AHI - New Patient Information

WELCOME TO THE BURLINGTON NATURAL HEALTH CENTRE PLEASE FILL IN THESE FORMS AS COMPLETELY AS POSSIBLE. THANKYOU!

PEDIATRIC HISTORY FORM

CHIROPRACTIC NEW PATIENT HEALTH HISTORY

Please complete this profile, the answers will help determine if Chiropractic can help your child. Child s Name: Parent 1 Name: Parent 2 Name:

Vibrant Life Healthcare 6105 Patricia Bay Highway Victoria, BC, V8Y 1T4

PEDIATRIC PRE-EXAM INFORMATION

Brisbin Family Chiropractic

CONSULTATION ADMITTANCE FORM

Address: Yes! I would like to receive your Monday Morning Health Tips.

What is your occupation? Company Name Do you have extended healthcare benefits? Yes No Benefits are personal or from work

Sydney Chiropractic, DR. DAVID DUNN

Universal Health & Rehabilitation, PC

Patient Information (please print clearly) Name: Date of Birth: mm/dd/yyyy / / Age: (to receive appointment reminders)

HEALTH INFORMATION FORM

Have you ever had any falls, accidents, or injuries? (Y or N) When? If yes, please explain

WELCOME TO The Chiropractors at Commerce Place

Have you ever been in a vehicular collision? (Please list date(s) and severity):

CHIROPRACTIC ASSOCIATES CLINIC

CHIROPRACTIC ASSOCIATES CLINIC

ACTIVE EDGE CHIROPRACTIC

3. How Long Has This Been An Issue?

PATIENT NAME DATE CONSULTATION QUESTIONNAIRE

Birth Date Age Social Security # Marital Status (circle) Have you had chiropractic care in the past? Yes No If yes, how long ago?

Name First Middle Initial Last Today s Date. Address Street City State Zip. Primary Phone # Cell # . Your Occupation Employer

Chiropractic Case History/Patient Information

HEALTH INFORMATION FORM

HEALTH RECORD REASON FOR THIS VISIT ABOUT YOU ABOUT YOUR SPOUSE HEALTH HABITS EXPERIENCE WITH CHIROPRACTIC

CHIROPRACTIC INTAKE FORM

Saleeby Chiropractic Centre, P.A.

SURNAME: FIRST NAME: Address: Who Is your GP and where do they practice? Friend: Please Name

Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION

Welcome to Compass Chiropractic!

Chiropractic Case History/Patient Information

Welcome to Medina Family Chiropractic and Acupuncture!

Patient Information. Card Care Number (PHN) Birthday (MM/DD/YY) Age: Would you like an reminder for your next appointment?

Patient Introduction

KEY TO LIFE CHIROPRACTIC

Patient First Name: Last Name: Street Address: City: State: Zip Code. Mobile Phone: Home Phone: Work Phone:

Revelation Chiropractic Health Profile

Name Age Date. Please list All your current health complaints, including the reason that brought you to our office:

Health and History Assessment ACCOUNT #: HIPPA: CTT:

Hamilton Back Clinic

BalanceChiropractic 7165 E University Dr. Suite 102 Mesa, AZ

RAINIER VALLEY CHIROPRACTIC P.S th Avenue S. Seattle, WA 98118

Who may we thank for referring you?

NEW PATIENT INFORMATION FORM

GENERAL PATIENT INFORMATION

Name Date / / Age Male/Female Address City State Zip Phone: Home Cell Carrier (Ex: AT&T, Verizon)

New Practice Member Application

Patient Re-Examination Form

PATIENT INTRODUCTION

Address City State Zip Code

Please fill out the following form in as much detail as possible. Please Print. Name. Address. City State Zip. Home Phone Office Phone.

Patient Profile. Full Name: Address: Work Phone: Date of Birth: Social Security #: (Circle One) Full Time / Part Time. Emergency Contact: Number:

KEY TO LIFE CHIROPRACTIC

WELCOME to the Florence Chiropractic and Wellness Center.

Matthews Family Chiropractic

Chiropractic Case History/Patient Information

SPARROW FAMILY CHIROPRACTIC

Chiropractic Case History/Patient Information. Social Security # Home Phone: Address: City: State: Zip: address: Fax # Cell Phone:

Adult New Patient Intake. Your Health Summary

Ages 6 to E. Lohman Ave Ste 22 Las Cruces, NM (575) Today's Date: Date of Birth: Phone Number with Area Code:

SPINE PROGRAM NEW PATIENT FORM

Subjective Medical History Information

DR. MARK HOOPER DR. MARK THURSTON DR. NICK HERBERT

Patient Information. Refurredby. Emergency Contact. Have you ever had chiropractic care before? For what problem? No ----

INNOVA Medical and Rehab Dr. Farhad Babakhani. BSc, DC, FCCRS, RAc # Elgin Mills Road East Richmond Hill, ON L4S 0B2

CHIROPRACTIC EXPERIENCE ABOUT YOU REASON FOR THIS VISIT HEALTH HABITS MEDICATIONS YOU TAKE SUPPLEMENTS YOU TAKE

Patient Intake Form Please Write Legibly

Family First Chiropractic

Kinetic Performance Center Glenmore Trail SW Calgary, Alberta T2V 4R6. Patient Information. Date of Birth (M/D/Y) Age: Sex: M F

LIST RESTRICTED ACTIVITY: CURRENT ACTIVITY LEVEL USUAL ACTIVITY LEVEL

Dr. Janet L. Yarger 510 Baxter Road, Suite 8, Chesterfield, MO

BalanceChiropractic 7165 E University Dr. Suite 102 Mesa, AZ

New Practice Member Paperwork

HISTORY OF PRESENT ILLNESS A. TELL US ABOUT YOUR PAIN PROBLEM

New Patient Intake Form 4 Market Place, PO Box 1585, Hollis, NH p: f:

Child (0-17) New Patient Intake Form. Child s Health Summary

Practice Member Profile

Patient Intake Form Gray Chiropractic Health Clinic LLC 360 East International Airport Road, Suite #4 Anchorage, Alaska (907)

PATIENT PERSONAL / CONFIDENTAL DATA

Patient Health Record

Van Wyk Chiropractic Center Terms of Acceptance and Privacy Policy

PATIENT INTAKE FORM Health & Wellness

Transcription:

Name: Cascadia Chiropractic Centre New Patient Information & Clinical Record Date: Date of Birth: Your age: Care Card #: Address: City/Prov: Postal Code: Phone: Cell: Work Phone: E-mail Address: Marital Status: Spouse s Name: Number of Children: Occupation: Employer: Student: Y N Are You Pregnant? If yes, due date: Are you claiming under WCB? If yes, Claim #: Are you claiming under ICBC? If yes, Claim #: Are you covered by DVA/RCMP? If yes, K/R #: How would you like to be reminded of your appointments? (Circle One) Text Email Phone If text, cell phone company (Bell, Telus, Rogers, Virgin, Fido etc.)? Do you have extended healthcare benefits? How did you hear about our office? A. PRESENTING COMPLAINT In your own words describe your main complaint or reason for your visit? When did it start? List date of onset or approximately how long ago it started: How did it start, did you do anything in particular to start this complaint? Have you had a similar complaint in the past? Yes / No Details: Have you seen another provider for this? If yes, how long ago? State the type of treatment (Chiro/Physio/MD/Specialist): Who provided it? What were the results? My complaint is progressively: Getting better Staying the same Getting worse This complaint is: Constant Comes and goes The symptoms are worse in the: Morning Daytime Evening

Which of the following makes your symptoms worse: Lifting Coughing Bending forward Exercising Bending Walking backward Sleeping Twisting Working Sneezing Driving Straining Reading Concentrating Dressing Homecare Playing sports Social Activities Which of the following make your symptoms better: Ice Exercising Heat Rest Stretching Taking Showering or bathing medications Bending a particular way Mark the diagram below to represent where you feel your symptoms now:

Rate your symptoms now: B. MEDICAL HISTORY Have you had chiropractic treatment before? By Whom? When? Surgeries you have had? Any relevant injuries or illnesses? Medications you currently take? Date of last foot examination: Check any significant medical conditions you have had: Migraines Arthritis Osteoporosis Fracture Cancer Infection Anemia/Blood Disorder Heart Disease/Stroke Spinal Fusions Sciatica/Disc Herniation Diabetes Double Jointed Psychological Disorder Depression Seizures Gastrointestinal disorder HIV or Hepatitis Check any significant symptoms you have: Headache Memory Loss Dizziness Nausea Loss of Balance Clumsiness Body or legs want to give out Tingling in arms Tingling in legs Bowel or bladder control issues Sleep loss Anxiety/ Stress Weight gain Weight loss (unexplained) Pain at night Night sweats Fatigue Diminishing Sight Double vision Blurred vision Pain with taking a deep breath Pain or unusual effort swallowing Difficulty speaking or slurring Diminished hearing Ringing in the ears Confusion Fainting/Blackouts Concussion Chest pain Stomach pain Pain with eating certain foods Menstrual issues Prostate or erectile issues Bedwetting Unusual stool (i.e. blood) Unusual cough or breathing Bruise easy On blood thinners Long-term steroid use

Cascadia Chiropractic Fees and Packages Standard pricing for those not covered under the MSP Low Income Premium Assistance: Initial Visit (Consultation and Examination) X-rays (if deemed necessary by chiropractor) Subsequent Office Visit Subsequent Child/Student Visit Shockwave Therapy (trigger point) Shockwave Therapy (pre-surgical) Spinal Decompression Treatment MLS Laser Therapy $36.00 $100.00 $65.00 $65.00 If you are eligible for coverage under MSP Low Income Premium Insurance, you are allotted 10 visits per calendar year. These visits are for chiropractic, massage therapy, podiatry, and physiotherapy combined. Your pricing is: Initial Visit MSP User Fee X-rays (if deemed necessary by chiropractor) Subsequent Office Visit MSP User Fee $27.00 Prices are subject to change based on severity of condition We reserve the right to bill for missed appointments All visits must be paid for at the time of service (unless otherwise arranged) For your convenience, we offer pre-paid packages so you do not have to stop at the reception desk every time you leave. Patient Name (please print) Signature of Patient or Guardian Date Witness Signature

CONSENT TO CHIROPRACTIC TREATMENT It is important for you to consider the benefits, risks and alternatives to the treatment options offered by your chiropractor and to make an informed decision about proceeding with treatment. Chiropractic treatment includes adjustment, manipulation and mobilization of the spine and other joints of the body, soft-tissue techniques such as massage, and other forms of therapy including, but not limited to, electrical or light therapy and exercise. Benefits Chiropractic treatment has been demonstrated to be effective for complaints of the neck, back and other areas of the body caused by nerves, muscles, joints and related tissues. Treatment by your chiropractor can relieve pain, including headache, altered sensation, muscle stiffness and spasm. It can also increase mobility, improve function, and reduce or eliminate the need for drugs or surgery. Risks The risks associated with chiropractic treatment vary according to each patient s condition as well as the location and type of treatment. The risks include: Temporary worsening of symptoms Usually, any increase in pre-existing symptoms of pain or stiffness will last only a few hours to a few days. Skin irritation or burn Skin irritation or a burn may occur in association with the use of some types of electrical or light therapy. Skin irritation should resolve quickly. A burn may leave a permanent scar. Sprain or strain Typically, a muscle or ligament sprain or strain will resolve itself within a few days or weeks with some rest, protection of the area affected and other minor care. Rib fracture While a rib fracture is painful and can limit your activity for a period of time, it will generally heal on its own over a period of several weeks without further treatment or surgical intervention. Injury or aggravation of a disc Over the course of a lifetime, spinal discs may degenerate or become damaged. A disc can degenerate with aging, while disc damage can occur with common daily activities such as bending or lifting. Patients who already have a degenerated or damaged disc may or may not have symptoms. They may not know they have a problem with a disc. They also may not know their disc condition is worsening because they only experience back or neck problems once in a while. Chiropractic treatment should not damage a disc that is not already degenerated or damaged, but if there is a pre-existing disc condition, chiropractic treatment, like many common daily activities, may aggravate the disc condition. The consequences of disc injury or aggravating a pre-existing disc condition will vary with each patient. In the most severe cases, patient symptoms may include impaired back or neck mobility, radiating pain and numbness into the legs or arms, impaired bowel or bladder function, or impaired leg or arm function. Surgery may be needed. Stroke Blood flows to the brain through two sets of arteries passing through the neck. These arteries may become weakened and damaged, either over time through aging or disease, or as a result of injury. A blood clot may form in a damaged artery. All or part of the clot may break off and travel up the artery to the brain where it can interrupt blood flow and cause a stroke. Many common activities of daily living involving ordinary neck movements have been associated with stroke resulting from damage to an artery in the neck, or a clot that already existed in the artery breaking off and travelling up to the brain. Chiropractic treatment has also been associated with stroke. However, that association occurs very infrequently, and may be explained because an artery was already damaged and the patient was progressing toward a stroke when the patient consulted the chiropractor. Present medical and scientific evidence does not establish that chiropractic treatment causes either damage to an artery or stroke. The consequences of a stroke can be very serious, including significant impairment of vision, speech, balance and brain function, as well as paralysis or death. Alternatives Alternatives to chiropractic treatment may include consulting other health professionals. Your chiropractor may also prescribe rest without treatment, or exercise with or without treatment. Questions or Concerns You are encouraged to ask questions at any time regarding your assessment and treatment. Bring any concerns you have to the chiropractor s attention. If you are not comfortable, you may stop treatment at any time. Please be involved in and responsible for your care. Inform your chiropractor immediately of any change in your condition. DO NOT SIGN THIS FORM UNTIL YOU MEET WITH THE CHIROPRACTOR I hereby acknowledge that I have discussed with the chiropractor the assessment of my condition and the treatment plan. I understand the nature of the treatment to be provided to me. I have considered the benefits and risks of treatment, as well as the alternatives to treatment. I hereby consent to chiropractic treatment as proposed to me. Name (Please Print) Date: Signature of patient (or legal guardian) Date: Signature of Chiropractor

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback