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Transcription:

Patient Admittance Form Mah Chiropractic Clinic 7222 Edgemont Blvd. N.W. World Health Club Calgary, AB. T3A 2X7 Phone: (403) 241-1886 Fax: (403) 241-0995 Name: (Family) (First) (Initial) Sex: Male Female Date of Birth: Age: Height: Weight: Home Address: City: Province: Postal Code: Phone Number: Home: Work: Cell: Email Address: Alberta Health Care Number: Your Occupation: In Case of an Emergency, who should we notify / phone: Have you received prior chiropractic care? Doctor s Name: Family Doctor s Name: Consent to Contact? What is your Chief Complaint? Is this an auto accident case, or have you recently been in an accident? Yes No Is this a workman s compensation case? Yes No Have you seen any other physician or health care practitioner for this complaint? Yes No I realize that Alberta Health Care Insurance does not pay 100% of the Doctor s recognized fee schedule, and that I am responsible for any difference between the Doctor s fee and the Insurance Commission s schedule of benefits. If this is an auto accident case, I understand that I am responsible for all debts incurred at this clinic, and that these are due payable within 10 days of a court or out of court settlement. Cancellation Policy: 24 hours notice is required. Otherwise your account will be charged for your missed appointment. please initial Date: 1 Signature:

General Systems Review Neck Respiratory Hair Gastro-Intestinal (continued) Allergies Asthma Bronchitis Chest Pain ChronicCough Emphysema Frequent Colds Hay Fever Pneumonia Smoker Skin Acne Boils Dermatitis Eczema Fungal infection Dryness Herpetic Infection Itching Psoriasis Rashes Scars Vision Redness Glaucoma Light Sensitivity Blurred Vision Cataracts Double Vision Cardiovascular Angina Arrhythmia s Arteriosclerosis Blood Clots Chest pain Cold / Blue hands/feet Low Blood Pressure High Blood Pressure Noticed heart racing Shortness of Breath Pounding Sensation Heart Attack CHF Ears Buzzing Discharges Infections Ringing Dizzy Head ADD/ADHD Concussion Headaches Insomnia Learning Problems Memory Decline Mental Illness Circle Hours of sleep per night 2-4 4-6 6-8 8-10 12+ Mouth Throat Bleeding Gum Disease Pyorrhea Halitosis Sore Throat Gastro Intestinal Digestive Disorders Gall Bladder Problem Gas and Bloating Irritable Bowel Syndrome Pain after eating Poor appetite Can not gain weight Alternating diarrhea & Constipation Black Stool Blood in Stool Mucous in stools Constipation Diarrhea Chron s Colitis Heart Burn Nausea Vomiting Ulcers Urinary Bed Wetting Bladder / Kidney infections Blood in Urine Burning Dribbling Hesitancy Incontinence Infections Kidney Stones Yeast Infection Decreased Frequency Increased Frequency Decreased Force Musculoskeletal Disc problems Fractures Low Back Pain Upper Back Pain Neck Pain Gout Hernia Muscle cramps Musclestrain Stiffness Numbness Osteoarthritis Osteoporosis Rheumatoid Arthritis Scoliosis Fibromyalgia Chronic Fatigue Vascular Anemia Frequently Bleeding nose Easy Bruising Leg pain after walking Raynauld s Swelling Thromophlebitis Varicose Veins 2

Neurological Alzheimer s Epilepsy Fainting Numbness Parkinson s Seizures Tremors Endocrine Diabetic Hyperthyroid Hypothyroid Increased Thirst Water Retention Cold Intolerance Female Reproductive Pregnant Yes No Due date Birth Control Pills Discharges Hysterectomy Lumps Menopause PMS Regular Period Sores Bleeding Between Periods Decreased Sex Drive Fertility Problems Frequent Periods Increase Menstrual Flow Painful cycle Pelvic Inflammation STD Male Reproductive Impotence Pus Discharge Rashes Testicular Pain Decreased Sex Drive Prostate Problems Trouble with Urination Other Alcoholic Cancer Chemotherapy Depression Hepatitis Night sweats Steroid Therapy Weight Problems Chronic Fatigue Syndrome Multiple Sclerosis Radiation Therapy Treatment History What type of practitioners have you seen for this condition? Please rate the effectiveness of these treatments 1 = Poor 5 = Good Chiropractic 1 2 3 4 5 Physiotherapy 1 2 3 4 5 Medical Doctor 1 2 3 4 5 Naturopath 1 2 3 4 5 Massage Therapist 1 2 3 45 Other 1 2 3 4 5 Surgeries Dates Family History Arthritis Genetic Problems Auto Immune Condition Cancer High Blood Pressure Diabetes High Cholesterol Hypothyroidism Hyperthyroidism Heart Attack Stroke Vascular Problems Childhood Conditions Please check the conditions that you have had: Measles Mumps Chicken Pox Whooping cough Scarlet Fever Diphtheria Rheumatic Fever Typhoid Fever Ear infections Tubes in Ears Chronic Ill Asthma Allergies What other information do you feel we should be aware of: 3

What are you looking for at our clinic? Help me Help you! It is very important to us that your experience at our clinic is a good one. Because of this we need to ask you a few more questions. 1. What results would you like to achieve by coming to our clinic? 2. Do you have a concern with the therapy that you would like to address before commencement of treatment (adjustments, changing clothes, previous experiences, office policies etc.)? 3. Is there a particular Technique / Therapy that you are would like us to use in your case? I would like the doctor to decide what the most appropriate technique is for my condition. Active Release Technique Soft Tissue Management System Modified Diversified (Manual adjusting by hand) / Activator Methods Acupuncture Traditional Chinese Medicine (TCM) Detoxifications Program Meridian Therapy / BIOSET / TCM Exercise rehabilitation protocols Strength and Rehabilitation with the WHC Trainers 4. Are there any other issues you would like to address? 4

Informed Consent to Chiropractic Adjustments And Soft Tissue Care Dr. B. Ritchie Mah DC. ART Dr. Jaime Mohan DC Mah Chiropractic Clinic 7222 Edgemont Blvd. N.W. World Health Club Calgary, AB T3A 2X7 Phone: (403) 241-1886 I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of therapy (Active Release Techniques, TCM procedures) and, if necessary, diagnostic x-rays, on me by Dr. B. Ritchie Mah and / or anyone authorized by Dr. Mah. I further understand and am informed that, as in all health care, in the practice of chiropractic, there are some very slight risks to treatment, including, but not limited to the following: Muscle strains and sprains, disc injuries, and strokes. I do not expect the doctor to be able to anticipate and explain all risks and complications and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed. Chiropractic Treatment, including spinal adjustment, has been the subject of government reports and multidisciplinary studies conducted over many years and have been demonstrated to be highly effective treatment for back pain, and musculoskeletal pain. I acknowledge I have discussed, or have had the opportunity to discuss, with either Dr. B. Ritchie Mah, Dr. Jaime Mohan, associates or staff, the nature and purpose of chiropractic treatment in general and my treatment in particular as well as the contents of this Consent. I therefore intend this consent to apply to all my present and future chiropractic care with Dr. B. Ritchie Mah and his associates at this or other clinic locations. Date: (D/ M / Y) Patient Name and Signature: Witness: (Print) (Print) (Signature) (Signature) 5

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