CHIROPRACTIC ASSOCIATES CLINIC

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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 Which Chiropractor are you visiting today? Dr. Donbrook Dr. Ogrady Dr. Pattison PATIENT INFORMATION Last Name: First Name: Personal Health #: _ Date of birth: MM DD YY Male Address: _ City: Province: Postal Code: _ Female _ Phone #: Home: ( _ ) _ - Cell: ( _ ) _ - Work: ( _ ) _ - Email: Family Doctor: Referring Practitioner: Place of Employment: Occupation: *NOTE: Text messaging is used to notify patients about upcoming appointments. Would you like to receive text messages from our office? Yes No EMERGENCY CONTACT INFORMATION Emergency Contact Name: Relationship: Phone #: Home: ( _ ) _ - Cell: ( _ ) _ - Work: ( _ ) _ - Will you be claiming your Chiropractic treatment under any of the following? Please check the appropriate box. WCB SGI RCMP DVA CAF Supplementary Services (SS) Claim #: Contact Person: Phone Number: ( _ ) _ - Have you seen a Chiropractor before? Yes No If so, who? For what complaint? Have you had any imaging on the area of concern? X-ray MRI CT Scan When? Where were the images taken?

PAST AND PRESENT MEDICAL INFORMATION Please circle any conditions that presently cause you problems. Please check any conditions that were a problem for you in the past. General Symptoms: Headache Fever Sweats Fainting Dizziness Convulsions Nervousness Loss of weight Numbness, pain, tingling Genitourinary: Poor appetite Blood in urine Kidney Infection Bed wetting Prostate trouble (men) Respiratory: Chronic cough Spitting up phlegm Spitting up blood Chest pain Difficulty breathing Have you recently had: Recent fever/infection Unexpected weight loss Pain waking you up at night Night sweats Bowel or bladder problems Numbness or tingling History of cancer Muscles and Joints: Stiff neck Backache Swollen joints Painful tailbone Foot trouble Shoulder pain Elbow pain Wrist pain Hand pain Hip pain Knee pain Arthritis Have you had any fractures? Cardiovascular: Pain over heart Stroke Hardening of Arteries High blood pressure Varicose veins Swelling of ankles Poor circulation Angina G.U. for Women: Painful menstruation Excessive flow Cramps or backache Vaginal discharge Swollen breasts Lumps in breasts Hot flashes Number of pregnancies: Number of children: Do you currently have any of the following symptoms: Dizziness Trouble swallowing Trouble speaking Fainting Double vision Unusual balance issues Nausea Numbness Gastrointestinal: Poor appetite Indigestion Excessive hunger Belching (gas) Nausea/vomiting Vomiting with blood Pain over stomach Constipation Diarrhea Hemorrhoids Jaundice Gall bladder problems Ulcer Eyes, Ears, Nose, Throat: Failing vision Crossed eyes Eye pain Deafness Earache Asthma Frequency colds Sinus infections Enlarged glands Enlarged thyroid Skin: Rashes Itching Bruises easily Dryness Boils Please list past/recent surgical procedures: Please list any medications you are currently taking:

REASON FOR VISIT What brings you into the office today? When did this complaint begin? How often does this complaint bother you? How long does it last? Is there ever a time when the pain does not bother you? How would you describe the pain? (Ex: Sharp, stabbing, achy, dull). Do you have any numbness or tingling in the arms or legs? Does your pain radiate down the leg or arm? Is there anything you find relieving (ex: ice, heat, rest)? Is there anything you find aggravating (ex: standing, bending over)? Have you received treatment/surgery for your current complaint? If so, from whom? Has there been a change in bowel/bladder function? No Yes Describe: If the complaint is related to your back, is the pain mainly in the back or leg? Back Dominant. Leg Dominant. Do you have a history of back problems? Do you have, or have you ever had, any medical conditions? (Ex: high blood pressure, high cholesterol, diabetes, cancer, heart attack, stroke, or any other medical condition or event). Please list. Please list any past or present medical conditions that your blood-related family members are affected by. (Ex: high blood pressure, high cholesterol, diabetes, cancer, heart attack, stroke, or any other medical condition or event). Please list. Do you have any allergies? If so, please list. Have you had any falls, motor vehicle accidents, or other traumatic incidents? What is your height? _ What is your weight? _

PAIN QUESTIONNAIRES Body Pain Diagram Please fill this out carefully. Use the appropriate symbols (provided below) to mark the area on the diagram where you feel the described sensation. Include all affected areas, including radiation of pain. Numbness = = = Burning Pain x x x Aching Pain ( ( ( Pins & o o o Needles Stabbing Pain / / / Level of Disability What is the overall level of disability? (Please check the most appropriate response). No Limitations. Mild Limitations able to do most activities with minor modifications. Moderate Limitations able to do most activities with modifications. Severe Limitations unable to perform most activities. Visual Analog Scale If you had to rate your pain on a scale of 0-10, (0 = no pain, 10 = most pain imaginable), where would you rate your pain right now? Please indicate on this scale with a check or circle. 0 1 2 3 4 5 6 7 8 9 10

CANADIAN CHIROPRACTIC PROTECTIVE ASSOCIATION Informed Consent to Chiropractic Treatment FORM L There are risks and possible risks associated with manual therapy techniques used by doctors of chiropractic. In particular you should note: a) While rare, some patients may experience short term aggravation of symptoms or muscle and ligament strains or sprains as a result of manual therapy techniques. Although uncommon, rib fractures have also been known to occur following certain manual therapy procedures; b) There are reported cases of stroke associated with visits to medical doctors and chiropractors. Research and scientific evidence does not establish a cause and effect relationship between chiropractic treatment and the occurrence of stroke. Recent studies suggest that patients may be consulting medical doctors and chiropractors when they are in the early stages of a stroke. In essence, there is a stroke already in progress. However, you are being informed of this reported association because a stroke may cause serious neurological impairment or even death. The possibility of such injuries occurring in association with upper cervical adjustment is extremely remote; c) There are rare reported cases of disc injuries identified following cervical and lumbar spinal adjustment, although no scientific evidence has demonstrated such injuries are caused, or may be caused, by spinal adjustments or other chiropractic treatment; d) There are infrequent reported cases of burns or skin irritation in association with the use of some types of electrical therapy offered by some doctors of chiropractic. I acknowledge I have read this consent and I have discussed, or have been offered the opportunity to discuss, with my chiropractor the nature and purpose of chiropractic treatment in general, (including spinal adjustment), the treatment options and recommendations for my condition, and the contents of this Consent. I consent to the chiropractic treatment recommended to me by my chiropractor including any recommended spinal adjustments. I intend this consent to apply to all my present and future chiropractic care. Dated this day of, 20. Patient Signature (Legal Guardian) Witness of Signature Name: (please print) Name: (please print) CCPA12.08 (ENGLISH)

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