WELCOME TO
SYNERGEA FAMILY HEALTH CENTRE
We invite you to experience the diversity of health and wellness specialties offered in our center.
Name :
Today's Date (m/d/y):
Your Birthday (m/d/y): Age:
Address:
Postal Code:
City:
Home Telephone:
Work Telephone:
Cell Telephone:
Occupation:
Employer:
Are you a full time student? If yes, where?
yes
Alberta Health Care Number:
E-mail address:
no
yes
Who is financially responsible for this account?
where
Would you like E-mail appointment reminders?
Is this a medical legal case?
yes
no
If yes, Name of your lawyer
no
If yes, initials
Is this a MVA?
yes
no
CREDIT CARD Name:_________________________ No. Visa/MasterCard:________________________ Expiry: _____________
WE REQUIRE 24 HOURS NOTICE WHEN RESCHEDULING YOUR APPOINTMENTS, OR YOU MAY INCUR A CHARGE
Whom may we thank for your referral to our center?
How did you find out about Synergea?
What is your Spouse's name?
Client Health Information
What is your present health concern?
When did this health concern start?
Who else have you seen for this concern? Is the concern getting better, worse or unchanging?
Name of your family physician:
Name of any and all specialists that you are seeing, with reason you are seeing them:
What health conditions have you sought care for in the last year?
Medication - Please list all medication both prescription and over the counter taken in the last year:
1.
2.
3.
4.
Reason Prescribed:
Reason Prescribed:
Reason Prescribed:
Reason Prescribed:
Please List all Vitamins and supplements taken in the last year:
1.
2.
3.
4.
Reason Taken:
Reason Taken:
Reason Taken:
Reason Taken:
Please indicate your current level of/level of consumption of the following:
None
Exercise
Sleep
Coffee
Tea
Tobacco
Alcohol
Junk Food
Stress
Light
Moderate
Heavy
Explain your indication:
Please indicate any of the professionals/health services you have benefited from and the approximate date of your last visit.
Chiropractor
Naturopath
Massage Therapist
Acupuncturist
Midwife
Cranio Sacral Therapist
Counsellor
Laser Therapy
Orthotics
Past Health Profile
You may still complete a more detailed health history with your practitioner, however, we ask for your full attention to detail as you
complete the selection below. Your attention to detail will allow the practitioners at Synergea to fully understand your health profile.
Please check any boxes that apply to your current condition and underline any conditions that you have previously experienced.
GENERAL:
Hypothyroid
MUSCULOSKELETAL SYSTEM:
Difficulty chewing / clicking jaw
Poor circulation/tissue swelling
Hyperthyroid
Low back pain/problems
Orthopedic Problem
Enlarged glands
Gas/bloating
Neck pain/problems
Hernia
Loss of weight
Constipation
Mid back pain/problems
Whiplash
Hypoglycemia
Diarrhea
Shoulder pain/problems
Bursitis - where?
Nervousness
Colitis
Arm or Elbow pain/problems
Vision problems
Black/bloody stool
Wrist or Hand pain/problems
Vertigo (Dizziness)
Hearing problems
Hemorrhoids
Hip pain/problems
Loss of feeling
Frequent colds or flus
Liver trouble
Leg pain/problems
Fainting
Gall bladder trouble
Knee or Foot pain/problems
Headaches
Frequent urination
Eczema
Pain/numbness in arms/legs
Tinnitus (ringing in ears)
Painful urination
Psoriasis
Painful tailbone
Confusion
Blood in urine
Varicose veins
Pain between the shoulders
Depression
Kidney stones
Asthma
Scoliosis
Insomnia (loss of sleep)
Prostate problems
Shortness of breath
Arthritis
Low energy
Anemia
Heart problems
Walking problems
Tremors/Twitching
BODY SYSTEMS:
NERVE SYSTEM:
CHECK ANY OF THE FOLLOWING THAT YOU HAVE EXPERIENCED
Alcoholism
Hypoglycemia
Cancer
Osteoporosis or Osteopenia
Venereal Infection
Hyperglycemia
Allergies
Auto Immune Deficiency
Epilepsy
Diabetes
Heart disease
Chronic fatigue or Fibromyalgia
Stroke
Tuberculosis
High Blood Pressure
Other:
Hospitalization. Please Explain
Surgery. Please Explain
Accident. Please Explain
CHECK ANY OF THE FOLLOWING THAT A FAMILY MEMBER HAS EXPERIENCED
Heart Disease
High Blood pressure
Arthritis
Neurological disorder
Cancer
Stroke
Diabetes
Other:
ARE THERE ANY OTHER HEALTH CONDITIONS WE DID NOT ASK ABOUT THAT WOULD BE IMORTANT TO KNOW ABOUT?
IF IT APPLIES PLEASE COMPLETE THE FEMALE CLIENT INTAKE FORM
PLEASE NOTE THAT PAYMENT IS DUE WHEN SERVICES ARE RENDERED UNLESS SPECIFICALLY ARRANGED WITH YOUR PRACTITIONER
PLEASE READ AND SIGN THE SYNERGEA FINANCIAL AND CANCELLATION POLICY
I CERTIFY THAT THE DETAILED HEALTH HISTORY IS COMPLETE AND ACCURATE TO THE BEST OF MY KNOWLEDGE.
Signature
Date (m/d/y):