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Transcription:

Merivale Chiropractic Clinic Merivale Mall 1642 Merivale Rd., Unit 360 Ottawa, ON K2G 4A1 Patient Introduction Personal History: Mr. Mrs. Miss Ms. Dr. Name: First Middle Last Your Address: _ City: Prov: Postal Code: Telephone: Home: Bus: Cell: Birth Date: (DD-MM-YYYY) - - Age: Male: Female: Occupation: Employer: Marital Status: Spouse s Name: Previous Chiropractor: Last visit to this Chiropractor: City: Reason for leaving: Present MD: Phone #: City: Referred to our Centre by: E-Mail: MVA Only Claim # - Policy # - Other Ins Max Claimable. 0 0 Spouse Ins Max Claimable. 0 0 Fill greyed out boxes only if applicable WSIB Only SIN # - - WSIB/ MVA ONLY I am fully aware that I am responsible for any balances on the account, in the event that your insurance does not approve the treatment plan given by the Doctor.

MERIVALE CHIROPRACTIC CLINIC Our Fee Structure Please note our fees for your initial visit: Consultation Complimentary Examination $90.00 Radiology $0.00-$84.00 (subsidized by OHIP) X-Ray Reading/Prescription $30.00 /Report Adjustment /Visit Modality / Traction Acupuncture with Adjustment $40.00 ($30.00 senior & student rate) $20.00 (in addition to regular visit fee) $25.00 (in addition to regular visit fee) Acupuncture 15 minute $50.00 30 minute $60.00 45 minute $80.00 1 hour $100.00 Please note that if you have been involved in a motor vehicle accident, our fee structure may differ due to the complexity of your needs in such cases. Please also note that your clinical Report of Findings, the time that your doctor will spend with you to go over your results, will be included in your initial fee. I fully understand the above fees and give my consent. I also give my consent to have the doctor take any x-rays he/she deems appropriate to better understand my problem and monitor my progress. Who is responsible for your bill: You: Spouse: Auto Ins.: WSIB: Extended Health Ins.: PLEASE SIGN IN PERSON: SIGNATURE: DATE: (Signature of Parent/Guardian required if patient under age 18) Thank You!

Merivale Chiropractic Clinic Merivale Mall 1642 Merivale Rd., Unit 360 Ottawa, ON K2G 4A1 Adult Consultation History Your Name: Your Main Complaint: Any other Complaints: How long have you suffered with this problem? What have you tried to do to get rid of this problem that DID NOT work? Have you become discouraged about handling this problem? When your problem is at its worst, how does it make you feel? How does this problem interfere with the following areas of your life? WORK: FAMILY: HOBBIES: LIFE: Does handling this problem cause stress for you? What do you do that makes this problem worse? How much older does this make you feel: On a scale of 1 to 10, with 10 being the highest, rate your commitment in helping us solve this problem:

What gives you some temporary relief? What is the pattern of this problem? Constant, Intermittent, Occasional Cyclic What is the effect it has on your body functions? How did it start? Are you on any type of medication?, Please list all: Could your problem have been caused by an injury at work? If yes, please give us the details: Have you been involved in an auto accident? Date of accident: Any difficulties from this? Do you have any children? # of children: Children s Names: Do they have any health problems that you are aware of? Is there any other information you would like us to know? SIGNATURE: DATE: For Women Only Date of your last menstrual period: Are using any means of contraception? Do you suffer from PMS? Do you experience severe cramping with your menstrual period? Thank You!

Merivale Chiropractic Clinic Merivale Mall 1642 Merivale Rd., Unit 360 Ottawa, ON K2G 4A1 MCC Symptom Diagram Patient Name: File #: Date: When you arrive at the clinic, in the diagrams provided below, please mark the areas on your body, which you feel best represent the pain(s) or sensation(s) you are experiencing. Please include all areas. Use the symbols provided below. Also, in order to complete the picture, please draw in your face. Symbols: Numbness Pins & Needles Burning Stabbing & Sharp Dull & Aching Stiff & Tight

Health Status Survey Patient Name: File #: Date: PLEASE FILL THIS PAGE OUT BEFORE COMING TO THE CLINIC: Please circle (O) any conditions or symptoms presently causing you problems. Please check ( ) those conditions or symptoms, which have been a problem to you in the past. GENERAL SYMPTOMS Loss of consciousness Blackouts Headache Fever Sweats Fainting Dizziness Clumsiness Convulsions Loss of sleep Numbness, pain or tingling Nervousness Loss of weight MUSCLES & JOINTS Stiff neck Backache Swollen joints Painful tailbone Foot trouble Shoulder pain Arm/Forearm pain Elbow pain Wrist pain Hand pain Arthritis Weakness or loss of strength E.E.N.T. Blurred vision Failing vision (one/both eyes) Crossed eyes Double vision Eye pain Deafness, Earache Ringing, buzzing, any noise in the ears Asthma Frequent colds Sinus infection Enlarged glands Enlarged thyroid Slurred or other speech problems Difficulty swallowing RESPIRATORY Chronic cough Spitting up phlegm Spitting up blood Chest pain Difficulty breathing CARDIOVASCULAR Bleeding Disorder High blood pressure Pain over heart Stroke Hardening of arteries Varicose veins Swelling of ankles Poor circulation Heart of blood disease Angina GENTOURINARY Trouble urinating Blood in urine Kidney infection Bed-wetting Prostate trouble G.U. FOR WOMEN Painful menstruation Excessive flow Hot flashes Irregular cycle Cramps or backache Vaginal, discharge Swollen breasts Lumps in breasts Have you ever been on birth control pills? Yes No Are you currently taking the birth control pill? Yes No # of pregnancies # of children Please inform the doctor if you have ever been tested for HIV or Hepatitis A/B/C. SKIN Rashes, itching Bruise easily Dryness Boils Hives (allergy) GASTROINTESTINAL Poor appetite Indigestion Excessive hunger Belching or gas Nausea Vomiting (blood?) Pain over stomach Constipation Diarrhea Hemorrhoids (piles) Jaundice Gall bladder trouble Intestinal worms Ulcer Diabetes Have you ever had any fractures? Have you ever been in a car accident? Yes No Have you ever been hospitalized? If yes, why? Are you currently a smoker? Yes No Have you ever smoked in the past? Yes No Have you ever been diagnosed with cancer? Yes No Do you take medication on a regular basis? Yes No If so, what? (blood thinner, blood pressure, etc.)

Merivale Chiropractic Clinic Merivale Mall 1642 Merivale Rd., Unit 360 Ottawa, ON K2G 4A1 CLINIC POLICIES Welcome to our office. Our goal is to serve you with exceptionally friendly and prompt service and provide the best family health care available. In return, you will receive restored health. It is our experience that our patients who follow these simple guidelines obtain the best results and greatest benefits to their health. CLINIC HOURS Our day is divided into office hours, adjustment hours and report hours. Reports and consultations should be scheduled during report hours only. Adjustment times are as follows: Dr. Leo Lachowich Dr. Tatyana Lachowich Monday: 3:00pm 06:45pm 7:30 11:45am Tuesday 7:00am 11:45am 03:00pm 06:45pm Wednesday 7:00am 11:45am 3:00pm 06:45pm 12:00pm 05:00pm Thursday: 3:00pm 06:45pm 03:00pm 06:45pm Friday: 7:00am 11:45am 7:00am 11:45am Saturday 10:00am 11:45am APPOINTMENT SCHEDULING/MISSED APPOINTMENTS The Chiropractor has designed a specific course of action to allow proper care, a must for spinal and postural correction. A personal appointment calendar has been designed for you to save time on each visit. If an appointment must be changed, 24 hours notice is required. All missed appointments should be made up later the same day or within 24 hours, let our front desk know and changes will be made accordingly. BROKEN APPOINTMENTS No show appointments are subject to a $40.00 (Forty Dollars) charge. Please give 24 hours notice so that the doctor may service others in need at your time. If appointments are repeatedly missed we will, regretfully, dismiss you from care. CHILDREN/FAMILY Once you understand that the nervous system controls and coordinates all functions of the body and subluxation interferes with nerve flow, we expect that you would want everyone in your family checked. We have costeffective family programs, and extend the opportunity to have your family checked at our expense within 7 days of starting care. FINANCIAL AGREEMENTS It is your payment that allows us to continue providing high levels of professional care, maintain our facility, and pay our staff. If for any reason you cannot keep your financial agreement, inform us immediately to eliminate any misunderstandings. INTERRUPTION OF CARE In the unlikely event it is necessary to discontinue your care for any reason, outstanding fees become payable and due immediately to eliminate any misunderstandings. REMEMBER Spinal correction and healing take time. If you do not feel satisfied with your body s responses, you agree make an appointment to discuss this with the Chiropractor. We want you to get the most from your chiropractic care. MODALITIES Patients receiving modality or traction table treatment are charged $20.00 in addition to regular visit fees. WSIB/ MVA ONLY I am fully aware that I am responsible for any balances on the account, in the event that your insurance does not approve the treatment plan given by the Doctor. PLEASE SIGN IN PERSON: Signed I have read and understand the above policies and agree to abide by them. Date:

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