Name: Date: AHC #: Email Address: Under Canada s new anti-spam legislation, we are required to ask you for your consent to contact you via email for appointment reminders and information regarding your health. Do you consent? (YES) (NO) Sign or Initial here Patient Health Record Relax Breathe Smile We are happy you are here! As a full spectrum Wellness Centre, we focus on your ability to be healthy. Our goals are firstly, to address the issues which brought you into our office, and secondly to offer you the opportunity of improved health potential and wellness services in the future. On a daily basis, you experience physical, chemical and emotional stress which can accumulate and result in a serious loss of health and compromised function. Most times the effects are gradual, not even detectable until they become serious. Answering the following questions will provide us with a profile of the specific stressors you face and have dealt with over your lifetime, allowing us to better assess the challenges to your health.
About You! Name: M F Address: City: Prov: PC: Phone (h): Phone (c): Phone (w): Birthdate: Age: # of Children: Married Single Divorced Separated Widowed Employer: Work Address: Type of Work: Person to Contact In Case of Emergency: Name: Phone Number: (h) (c) We change people s lives through inspiration, empowerment, and excellent health care delivery in a beautiful, efficient team environment making us Calgary s first choice for natural health care. Reason For This Visit Describe the purpose of this visit: Is this visit due to or in any way related to: Job Sports Auto Accident Fall Chronic Discomfort Injury Other Please explain: If job related, have you reported your accident to your employer? Will this visit be part of a WCB Claim? When did this condition begin? Has this condition: gotten worse gotten better stayed the same comes and goes Does this condition interfere with: work/school sleep daily routine athletic activities Explain: Have you seen anyone else for this condition? Doctor or Clinician s Name: Type of Treatment: Result:
Experience with Chiropractic Who referred you to our office? Have you ever been adjusted by a Chiropractor? Reason for visits? How long ago? Doctor s Name? Date of last visit? Has any adult in your family seen a Chiropractor? Has any child in your family seen a Chiropractor? Were you aware that: Doctors of Chiropractic work with the nervous system? The nervous system controls all bodily functions and systems? Chiropractic is the largest natural healthcare profession in the world? If Chiropractic care starts at birth, you can achieve a higher level of health throughout your whole life? We look at the entire individual to get to the cause of problems, rather than simply treating symptoms. Unlike other NW Calgary chiropractors, we have a multidimensional focus and take an integrated approach when helping practice members. About the Spouse or Parent Name Employer Work Phone Type of Work
Goals For My Care People see Chiropractors for a variety of reasons. Some go for relief of pain, some to correct the cause of pain and others for correction of whatever is malfunctioning in their bodies. Your Doctor will weigh your needs and goals when recommending your treatment program. Please check the type of care desired so that we may be guided by your wishes whenever possible. Relief Care Symptomatic relief of pain or discomfort Corrective Care Corrective and relieving the cause of the problem as well as the symptoms Comprehensive Care Bring whatever is malfunctioning in the body to the highest state of health possible with Chiropractic care I want the Doctor to select the type of care appropriate for my condition Patient Signature Date Health Systems Review Please check each of the diseases or conditions that you have now or have had in the last 6 months. Headaches Congenital Heart Defect Ankle swelling Kidney problems Arthritis Sinus problems Hepatitis Heart Surgery/Pacemaker Vison problems Rheumatic fever Difficulty swallowing Motor Vehicle Accident Heart problems Cancer Loss of sleep Surgery (list) High/Low Blood Chemotherapy Pain between For Women: Pressure Difficulty breathing shoulder blades Infertility issues Yes No Dizziness Frequent neck pain Asthma Are you pregnant Yes No Psychiatric problems Numbness or pain in Shingles Are you nursing Yes No Thyroid problems Arms/Legs/Hands Alcohol/Drug abuse Using birth control Yes No Lower back problems Venereal Disease Digestive problems Do you experience painful HIV/Aids Ulcers/Colitis Diabetes menstruation Yes No Heart Attack/Stroke Tuberculosis Excess/Painful urination Irregular cycles Yes No Health and Lifestyle Habits How many fruits and vegetables do you eat per day? 0 1-2 3-4 5+ How many glasses of water do you drink per day? 0 0-2 2-6 6-10 10+ Do you smoke? Y N packs/day Do you consume salty/sugary treats? Heavy Moderate Light None Do you drink alcohol? Y N drinks/day Do you wear Heel lifts Insoles Arch supports N/A Do you drink coffee? Y N cups/day How do you rate your energy? High Normal Low Describe your sleep: Do you do cardiovascular exercise regularly? 0x per wk 1x per wk 2-3x per wk over 4x per wk Do you do strength training? 0x per wk 1x per wk 2-3x per wk over 4x per wk Family Health History Diabetes Depression MS Heart Disease Osteoporosis Stroke High Blood Pressure Arthritis Cancer Adverse Vaccine Reactions Digestive Issues/Irritable Bowel
Stress History Name your biggest PHYSICAL Stressors Name your most significant CHEMICAL and/or NUTRITIONAL stressors Name your largest sources of MENTAL and/or EMOTIONAL stressors List any other sources of stress Why This Form Is Important Medications/Supplements You Now Take Certain drugs can cause or neuro-musculoskeletal symptoms, therefore it is important for our chiropractors to know what medications you are currently taking. The symptoms that you have presented to the clinic with may be related to these medications. If you are unsure of the medication name and dosage it is imperative that you make note of it and let us know at your next visit. Likewise certain nutritional supplements can alleviate neuro-musculoskeletal symptoms and it is just as important for our chiropractors to know if you are currently taking any nutritional supplements. Stimulants Antidepressants Blood Thinners Muscle Relaxers Birth Control Insulin Acid reducers Blood Pressure Medication Pain Killers (NSAIDS/Aspirin/Ibuprofen) Please list your current prescription and over-the-counter medications: Medication Dosage Reason Duration Please list all nutritional supplements you are currently taking: Supplement Name Dosage Reason Duration Patient Name Dated this day of, 20 Patient Signature Witness Signature
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 rather recent studies indicate 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, 20. Patient Signature or Legal Guardian Witness of Signature Name: (please print) Name: (please print) Beacon Hill Chiropractic & Massage Dr. Michael Schmolke and Associates 11636 Sarcee Trail NW Calgary, Alberta T3R 0A1 www.getbetterfaster.ca