Cascadia Chiropractic Centre

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Name: Address: Dr. Simpson Leung Cascadia Chiropractic Centre New Patient Information & Clinical Record Date: City: Province: Postal Code: Phone: Cell: Work Phone: Date of Birth: E-mail Address: Care Card Number: Marital Status: Spouse s Name: Number of Children: Occupation: Employer: Have you had Chiropractic Treatment Before? By whom? Last Visit: 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 (Dept. of Veterans Affairs)? If yes, please give K# How would you like to be reminded of your appointments? (Circle One) Text Email Phone If by text, what is the name of your cell phone carrier? Who may we thank for referring you? Current Health Complaints/Reason for consulting our office (where is your pain) : 1. For how long? 2. For how long? Rate your pain above on a scale from 0 10. (0=no pain, 10= severe pain) 1. 2. Does pain or numbness spread? If yes, where? Do you have headaches? Does your neck grind or grate? Have you had same or similar problem(s) before? If so, for how long? Father, mother, sister, brother, children with similar problems? If so, who? Other doctors you have seen for this problem: Have you had any falls or accidents? If yes, please explain: Surgeries you have had: Medications you currently take: Date of your last foot examination? Do you have extended health care benefits? The doctor of the future will give no medicine but will interest his patients in the care of the human frame, diet, and in the cause and prevention of disease Thomas A. Edison

Please check if you have had the following, or if you currently suffer from the following: Please circle the areas where you have any problems Condition, symptom Constantly or Sometimes or or problem Frequently Occasionally 1 of Headache Migraines Neck Pain Shoulder Pain Arm/Hand Pain Mid Back Pain Low Back Pain Hip Pain Leg/Foot Pain Disc Problems Arthritis Other Joint Pain Numbness Joint Swelling Dizziness Nausea Weakness Fatigue Nervousness Insomnia Heat Problems Frequent Colds Nose Bleeds Ringing in Ears Earaches Hearing Loss Cough Chest Pains Female Problems Allergies Asthma Cancer Osteoporosis Diabetes Hypoglycemia Digestive Problems Urinary Problems Skin Conditions Other Below, Please fill in any other heath information you feel we might need for your care: Your Signature Below Please Date:

Cascadia Chiropractic Fees and Packages Standard pricing for those not covered under the MSP Low Income Premium Assistance: Initial Visit (Consultation and Examination) $50.00 X-rays if deemed necessary by Dr. Leung $75.00 Subsequent Office Visit $45.00 Shockwave Therapy (trigger point) $50.00 Shockwave Therapy (pre-surgical) $100.00 Spinal Decompression Treatment $65.00 MLS Laser Therapy $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 $25.00 X-Rays if deemed necessary by Dr. Leung $75.00 Subsequent Office Visit MSP User Fee $20.00 Prices are subject to change based on severity of condition 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. As a courtesy to you the office will provide a reminder (phone/email/text) however, you are fully responsible for your appointments. We reserve the right to bill for any missed appointments. 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. PAGE 1 OF 2

CCPA 09.14 Page 2 of 2 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: 20 Signature of patient (or legal guardian) Date: 20 Signature of Chiropractor PAGE 2 OF 2

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