Date: Full Name: Preferred Name:
Referred by Friend/Family Referred by Medical Doctor Internet/Website Street Sign
Referred by Trainer Walk In Health Care Event
*Whom may we thank for this referral?
* We communicate appointment reminders, invoices, receipts, exercise programs & health tips via email. We hate spam, but we really value educational information. Do we have permission to utilize your email address ? Yes No
Family Medical Doctor’s Name:
Date of last MD visit:
Date of last physical examination:
What therapies have you previously received? Chiropractic Massage Acupuncture Physiotherapy
Clinic:
Reason:
Sex: Male Female Birthdate: Age: Marital Status:
Alberta Health Care #: Street Address:
Cell#: Postal Code: City: Prov:
Home #: Email:
Occupation: Employer:
Emergency Contact: Relationship: Phone #:
DD/MM/YYYY
* Communication between healthcare providers can greatly improve the quality and safety of patient care. If necessary, do you consent to allow your health provider at PHP to contact your medical doctor? Yes No
Do you have a private insurance plan? No Yes (Self) Yes (Spouse) Yes (Parent)
Name of primary policy holder (Spouse/Parent):
Policy #:
Member ID: Group #: (ABC Only)
Is this a Workman’s Compensation Case (WCB)? No Yes
Date of Accident:
Is this a Motor Vehicle Accident Case (MVA)? No Yes
Date of Accident:
Alberta Blue Cross (ABC)
Green Shield
Chamber of Commerce
Industrial Alliance
Other:
SunLife
Standard Life
Desjardins
Johnson
Great West Life
SSQ Financial
Cowan
Manulife
Which Company?
Other:
HOW DID YOU FIND US?
Acupuncture Intake Form
Patient Information 1/12
Medical Information 2/12
Page /41 5004 Elbow Drive SW Calgary, AB, T2S 2L5 403-287-7325// //
Extended Health Benefits & Other Insurance 3/12
How Did You Hear About Us? 4/12
DD/MM/YYYY
What is the character of the pain? Dull & Achy Stiff & Tight Sharp Pins & Needles Numb Burning
Please rate your pain: (LEAST) 0 1 2 3 4 5 6 7 8 9 10 (WORST)
When do you feel the pain? Constantly Intermittently Only at Night Only in the Morning
Does the pain radiate down your legs or arms? No Yes; Describe:
What aggravates your pain? Sitting Standing Rest Bending Lifting Exercise Weather Changes
What relieves your pain? Rest Movement Heat Ice Massage Medication:
Have you seen anyone else for this condition? No Yes; Who:
Have you had any imaging for this condition: X-Ray CT MRI Ultrasound Date:
Does this problem interfere with: Work Family & Social Life Sports & Hobbies Sleep
What is your commitment to correcting this problem: 0 1 2 3 4 5 6 7 8 9 10
''''''''''''''
E/$I!G/$%)1![!E/+6#+5$:3/4!W:V'+0![!>*#+)(!P/1$2!F%-:-3!!!!!!\]]^!B%2#&!;+-,/!>H4!F$%7$+04!9J4!"_>!_S\!!! !!̂ ]` C_ab Cb`_\ !
@9++%&#'3%"0#4'@*&.$#$*&'7A*+'(&B9+C'
E+-5$+0!F#5*%$-:)<!=================================================!!H1/:!.-.!)1-(!2/7-:R!==============================!
G$,/!0#'!1$.!)1-(!2/6#+/R!! !D#!! !N/(c!&1/:<!===================!!W(!-)!7/))-:7<!!!H#+(/!! !J/))/+!! !D#)!F1$:7-:7 !
W(!)1/!3#:.-)-#:<!!!H#+I CP/%$)/.!!! !9')# CP/%$)/.!!! !>*#+)(CP/%$)/.!!! !A$%%!!!O)1/+<!==============================!
H1$)!-(!)1/!31$+$3)/+!#6!)1/!*$-:R!!;'%%![!9310!!!!>)-66![!"-71)!!! !>1$+*!!! !E-:(![!D//.%/(!!! !D'52!! !J'+:-:7!! !
E%/$(/!+$)/!0#'+!*$-:<!!!KSB9>" L!!!! KHOP>" L!
H1/:!.#!0#'!6//%!)1/!*$-:R!!! !F#:()$:)%0!!!! !W:)/+5-))/:)%0!!!! !O:%0!$)!D-71)!!!!!O:%0!-:!)1/!@#+:-:7!
;#/(!)1/!*$-:!+$.-$)/!.#&:!0#'+!%/7(!#+!$+5(R!! !D#!!! !N/(c!;/(3+-2/<!================================================!
H1$)!$77+$,$)/(!0#'+!*$-:R!! !>-))-:7!! !>)$:.-:7!!! !J/:.-:7!!! !S-6)-:7!!! !B?/+3-(/!!! !H/$)1/+!F1$:7/(!!! !P/()!
H1$)!+/%-/,/(!0#'+!*$-:R!! !P/()!!! !@#,/5/:)!!! !G/$)!!! !W3/!!!!@$(($7/!!! !@/.-3$)-#:<!==========================!
G$,/!0#'!(//:!$:0#:/!/%(/!6#+!)1-(!3#:.-)-#:R! !D#!!! !N/(c!&1#<!======================================================!
G$,/!0#'!1$.!$:0!-5$7-:7!6#+!)1-(!3#:.-)-#:<!! !gCP$0!!!! !F"!!!! !@PW!!!!!h%)+$(#':.!!!!!;$)/<!=======================!
;#/(!)1-(!*+#2%/5!-:)/+6/+/!&-)1<!!!H#+I!!!!! !A$5-%0![!>#3-$%!S-6/!!!!!>*#+)(![!G#22-/(!!! !>%//*!
H1$)!-(!0#'+!3#55-)5/:)!)# !3#++/3)-:7!)1-(!*+#2%/5<!!!]!!!!!d!!!!!!_!!!!!!`!!!!!!^!!!!!!\!!!!!!e!!!!!!b!!!!!!a!!!!!!f!!!!!!d]!!!!!
;#!0#'!1$,/!$:0!(/3#:.$+0!3#5*%$-:)(R!==================================================================================!
================================================================================================================================
=!DC,E#*,';$"F+", '
E%/$(/!'(/!)1/!(052#%(!2/%#&!)#!5$+I!$%%!#6!)1/!$+/$(!#:!)1/!.-$7+$5!)1$)!JB>"!+/*+/(/:)!)1/!*$-:!$:.!
(/:($)-#:(!)1$)!0#'!$+/!FhPPBD"SN!/?*/+-/:3-:7<! !
!
Please use the symbols below to mark all of the areas on the diagram that BEST represent the pain and sensations that you are
CURRENTLY experiencing:
Primary Complaint:
Have you had this before? No Yes; when:
Is the Condition: Work-Related Auto-Related Sports-Related Fall Other:
What type of care are you seeking? Preventative Acute Long-Term
When did this begin?
Is it getting: Worse Better Not Changing
Page /42 5004 Elbow Drive SW Calgary, AB, T2S 2L5 403-287-732// //
Current Health 5/12
Symptom Diagram 7/12
If You Have Pain &/Or Injury... 6/12
Do you have a healthy & balanced diet? No Don’t Know Yes, I think so Yes, definitely
What are your stress levels? Extreme High Moderate Low Very Minimal
Have You Ever Had...
Fracture? No Yes; where/when:
Major Surgery? No Yes; where/when:
Car Accident? No Yes; when:
A Concussion? No Yes; when/how:
Been Hospitalized? No Yes; when/why:
Been Diagnosed With: Cancer HIV/AIDS Hepatitis A/B/C Other: When:
Do you have any allergies? No Yes; List:
Please list any medications/supplements that you are currently taking:
High Blood Pressure? No Yes; when:
High Cholesterol? No Yes; when:
Are you pregnant? No Yes; Due Date:
# of Past Pregnancies: # of Children:
Is there a family history of:
*Mother’s Side:
*Father’s Side:
Heart Disease Stroke Cancer Diabetes Arthritis Other
Please check the box of any conditions or symptoms that you have had in the past six months:
Fever
Fainting
Night Pain
Headaches
Loss of Sleep
Loss of Weight
Anxiety/Nervous
Excessive Sweating
General:
Angina
Chest Pain
Varicose Veins
Ankle Swelling
Poor Circulation
Previous Stroke
Irregular Heartbeat
Previous Heart Attack
Cardiovascular:
Dizziness
Paralysis
Nausea
Convulsions
Clumsiness
Blurred Vision
Loss of Balance
Numbness/Tingling
Neurological:
Asthma
Sore Throat
Frequent Colds
Chronic Cough
Sinus Infections
Spitting up Blood
Spitting up Phlegm
Difficulty Breathing
Respiratory:
Kidney Infection
Menopause
Painful Breasts
Prostate Trouble
Trouble Urinating
Blood in Urine/Stool
Painful Menstruation
Irregular/Absent Cycle
Genitourinary:
Earaches/Infection
Hearing Difficulty
Eye Pain
Ringing in Ears
Worsening Vision
Eyes/Ears/Nose/Throat:
Shoulder/Arm Pain
Knee/Leg Pain
Hip/Groin Pain
Wrist/Hand Pain
TMJ/Jaw Pain
Fibromyalgia
Arthritis
Disc Herniation
Low Back Pain
Mid Back Pain
Neck Pain
Elbow Pain
Muscle & Joint:
Sciatica
Ankle/Foot Pain
Gout
N/(c!;/(3+-2/<!================================================
;#!0#'!1$,/!$:0!(/3#:.$+0!3#5*%$-:)(R!==================================================================================!
=================================================================================================
Page /43 5004 Elbow Drive SW Calgary, AB, T2S 2L5 403-287-7325// //
Health History 8/12
Family History 9/12
Lifestyle 10/12
Health Status Survey 11/12
Are you currently a smoker? No Yes; amount:
Do you exercise regularly? No Yes; type & frequency:
Do you consume alcohol? No Yes; amount/frequency:
Did you smoke previously? No Yes; when:
Coffee? No Yes; amount:
Pregnancy & Birth:
Are you Pregnant? No Unsure Yes; Estimated Due Date:
Undergoing Fertility Treatments; Describe:
Number of Past Pregnancies: Number of Abortions: Number of Miscarriages:
Vaginal Birth; How Many & When: C-Section; How Many & When:
Pregnancy &/or Birthing Complications:
Contraception & Cycle:
Birth Control Pill IUD Other:
Number of Days in your Cycle: Number of Days of Flow:
Irregular Cycle; Explain:
No Period; Approximate Date of Last Period:
Heavy Flow Light Flow Flooding Clots; Size: When:
Spotting Brown Light Pink/Red Start of Period End of Period Other:
Other Symptoms:
Mood Swings Weepy Breast Tenderness Pain with Ovulation Vaginal Dryness
Discharge; Describe Character & When:
Hot Flashes: Mild Severe Frequent Irregular Mostly at Night
Change in Appetite: Increased Decreased Cravings
Change in Bowels: Constipation Loose Stools Fluctuating
Cramping: Mild Severe Where: Abdomen Low Back Legs
Irritability: Mild Severe Depression: Mild Severe
Headaches Migraines; Describe Symptoms & Frequency:
Additional Comments:
Page /44 5004 Elbow Drive SW Calgary, AB, T2S 2L5 403-287-7325// //
Women’s Health 12/12