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#3 1810, 8 th Street East, Saskatoon SK S7H0T6 Phone (306) 373-5209 Fax (306) 373 5207 Michelle Kormos, Osteopathy (current study) Patient Medical History Please complete the entire medical history and write N/A in any section that is not applicable. Name: Date: Email: Home Phone Number: Work Phone Number: Cell Number: Mailing Address: Date of Birth: Age: Today s Visit Reason for seeking treatment: Is it possible the pain or injury is related to a specific incident? NO YES Date of incident: 1

Draw the location and type of your pain on the body outlines and mark how intense the pain is on the scale. Other Care Practitioners List all doctors, therapists, etc. that you are currently seeing and frequency of visits. 1. 2. 3. 4. 5. Medications: List medications you are taking now (including vitamins, Aspirin, Tylenol, Advil, etc.) the reason for each and the name of doctor who prescribed or recommended it: Medications: Who prescribed it: Purpose of Medication: Allergies to medications: Other Allergies: 2

Neurological Health: Please check if you have had any of these and give age of onset, frequency of incident and details. fainting spells Dizziness Equilibrium/Balance Motion Sickness Tinnitus (ear ringing) Hearing Loss Vision Problems Memory Problems Attention/Concentration Problems Weakness in Extremities Burning in Extremities Numbness in Extremities Cramps in Extremities Difference between sides of body Other Have you had any diagnostic tests done (eg.x-ray, EMG, Cat scan, MRI)? If yes, please give doctor s name, where the test was done, approximate date, and results. 1. 2. 3. 4. 5. Ear/Nose/Throat Please check if you have had any of the following and give the age and onset and frequency or list as ongoing Ear infections Tinnitus Tubes in ears Recurring sore throat Sinus congestion Sinusitis Allergies Tonsillitis Strep Throat Mouth breather Other ear/nose/throat dysfunction 3

Digestive Health Please check if you have had any of these and give age and onset and frequency or list as ongoing Ulcer/ Stomach Problems Acid reflux H Pylori infection Obesity Underweight Diarrhea Constipation Hemorrhoids Hiatus Hernia Chrohn s disease Colitis Irritable bowel syndrome Gallbladder problems Liver problems Pancreas problems Other Urinary Health Bladder Problems Kidney Problems Urinary Tract Infections Incontinence Other Cardiovascular Health Anemia Diabetes Hypoglycemia High Blood Pressure Low Blood Pressure Heart Problems Other 4

Respiratory Health Asthma Had wind knocked out of you Difficulty breathing Bronchitis Pneumonia Croup Whooping cough Other respiratory problems _ Reproductive History Please circle any of the following you have experienced PMS Menstrual Cramps Heavy Bleeding Infertility Miscarriages Hot Flashes Other: Number of pregnancies Complications: Musculoskeletal Back Problems Neck Problems Scoliosis Bladder Problems Rheumatoid Arthritis Osteoarthritis Other Please list all fractures/breaks/sprains/torn muscles or ligaments and their after effects, if any. 5

Cranial/Sacral Injuries Please list all head and tailbone injuries (hit your head, fell on your tailbone, etc.) treatment, after effects. Headaches Age of Onset: Frequency: Where do you feel them?: How long do they last? : Any diagnosis/treatment: Dental & TMJ TMJ/Jaw Problems Tooth Extractions Root Canals Braces Other Surgeries/Procedures Please list all surgeries & procedures with approximate date and your age at the time of the surgery. (include dental work) 1. 2. 3. 4. 5. 6. Immune/Lymphatic Autoimmune disease Hypersensitivity HIV/Aids Other 6

Integumentary (Skin) Psoriasis Shingles Athletes Foot Rash Warts Herpes Acne Other Endocrine Diabetes (type 1) Thyroid disorder Other Lifestyle: Please list any habits, interests or hobbies (nail biting, play musical instrument, yoga, hockey, etc.) when you partook in the activity and the duration. 1. 2. 3. 4. 5. Do you smoke? No Yes How much? For how long? Quit How long ago? Do you drink alcohol? No Yes How many drinks per day? week? Do you binge drink? Do you take any recreational drugs? No Yes In the past? Please list present and previous occupations and duration Stress Level (1-10) Energy Level (1-10) 7

Please list Special Diets: (ie. milk free, low fat, vegetarian, gluten free, etc) What exercising do you do? How often? How long at at time? Please include competitive sports. Sleep: Restful No Yes Number of hours per night? number of times you wake in the night? Reason for waking up? Wake feeling rested? Other Major Life Experiences Please list all other major injuries not mentioned above (car accidents, hospitalizations, falls, sport or play injuries, etc.) Other Health Conditions/Past Illness Please circle any you have had. Measles Rubella (German Measles) Chicken Pox Mumps Thyroid Hypo or Hyper Scarlet Fever Rheumatic Fever Cancer Depression Anxiety Hepatitis A Hepatitis B Infectious Mononucleosis Meningitis Staph Infection Yeast Infection Other: 8

Family History Is there any history of the following in your family other than yourself? If yes, please list the family member(s) next to the corresponding condition. Cancer Diabetes Hypoglycemia High Blood Pressure Low Blood Pressure Heart Problems Asthma Other Respiratory Problems Allergies Kidney Problems Gallbladder Problems Weight Problems Headaches Structural Problems (back, neck, etc) Other Please circle Y or N depending on the health of your family member, if N is circled please describe issues/conditions/illnesses. Mother Healthy Y N : Deceased Cause: Father Healthy Y N : Deceased Cause: Siblings # Healthy Y N : Deceased Cause(s): 9

Booking Agreement I understand and agree that 24 hours notice is required to change/cancel appointments and I will be responsible for payment of services in full if less than the required 24 hours notice is given. Patient Signature Date Patient Name (printed) Work Waiver Release & Indemnity Agreement I, consent to and authorize Michelle Kormos to administer Manual Therapy treatments. I am aware that all risks of injury to myself are not the responsibility of Michelle Kormos. I understand that Manual Therapy does not replace medical treatment. Michelle Kormos does not provide medical advice, diagnosis or medical treatment. All information provided is for educational and informational purposes and is not meant to substitute for the advice provided by your doctor. I am also aware that there is no guarantee, warranty or assurance has been made to me as to the results that may be obtained. I have certified that I have read and understand this entire informed consent, agree to the above and and agree to be treated. If the patient is a minor I give my consent to have them treated. Signature of patient (or parent/legal guardian): Printed Name: Date: Witness: 10

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