Inglewood Family Health Centre
Consultation Admittance - Patient Information
Last Name:
First Name:
Phone: Home:
Wk:
Address:
Postal Code: _________________
Gender: □ Male □ Female Weight:
Date of Birth: (m/d/y)
Occupation:
Employer:
Medical Doctor:
AHC #:
Previous Chiropractor:
Cell:
City:
Height:
Last Seen:
Last Seen:
Reason for appointment?
When did the condition begin?
Have you ever had similar problems? □ Yes □ No
Have you had X-rays, MRI or other tests for this condition? What tests &
when?
Contact Person(In case of emergency):
Phone: Cell: _________
Home:
Work:
Provide email if we may contact you by this method (appt. reminders only)
_____________
How did you find out about our clinic? If recommended, please state name:
Although our office does not direct bill third party insurance coverage, we do encourage our patients to check
their benefit package regarding their coverage for the following services: chiropractic, massage therapy,
orthotics. We will issue you receipts that you can submit for reimbursement.
HEALTH
Case History
Please circle degree of pain (0=none, 10=severe pain)
0 1 2 3 4 5 6 7 8 9 10
Using the symbols below, mark on the diagram where you feel pain.
Numbness = = =
Sharp/Stabbing
///
Dull Ache OOO
Pins/Needles
+++
Burning
XXX
Other _____ ^ ^ ^
Other Symptoms:
Please mark any of the following conditions or symptoms that you have now or
have experienced:
□ Headaches
□ Pain in hands or arms
□ Chest pains
□ Neck pain
□ Numbness in hands or arms
□ Whiplash Injury
□ Loss of consciousness
□ Bone spurs
□ Pain in legs or feet
□ Low back pain
□ Numbness in legs or feet
□ Nervousness
□ Fatigue
□ Tension
□ Depression
□ Irritability
□ Lights bother eyes
□ Dizziness
□ Loss of memory
□ Pain between shoulders □ Shoulder pain
□ Neck Stiff
□ Sinus
□ Joint swelling
□ Shortness of breath
□ Fever
□ Asthma
□ Loss of balance
□ Allergies
□ Ringing in ears
□ Cold hands
□ Jaw/TMJ problems □ Cold feet
□ Heart attack
□ Sudden collapse (still conscious)
□ High blood pressure
□ Stroke
□ Cancer
□ Painful urination
□ Diabetes
□ Diarrhea
□ Constipation
□ Stomach upset
□ Heartburn/reflux
□ Weight loss
□ Loss of smell or taste
□ Menstrual cramps
□ Menopause
List ALL medications currently taken:
Any surgery? (Type and Date)
Auto Accidents? (Dates)
Any Broken Bones? (Dates)
Work Related Accidents? (Dates)
I hereby certify that the statements and answers given on this form are accurate
to the best of my knowledge and understand that it is my responsibility to
inform this office of any changes in my health. I agree to allow this office to
examine me further for evaluation.
Patient Signature:
Date:
Parent/Guardian Signature (if applicable):
Insurance – Release of Information (Optional)
I hereby confirm that Inglewood Family Health Centre may release information
concerning my treatment (dates, practitioner, type of treatment, fees paid)
which may be requested by my Insurance Company.
Patient Signature:
Date:
Cancellation Policy
Cancelling or rescheduling appointments must be done 24 hours in advance. There
may be a charge for missed appointments.