Horizon Joint Revuvenation Centre Intake Form

Your name*

Your email*

Phone Number*

Gender*
MaleFemaleOther

Date of Birth*

Health Care Number *

Address*

City*

Province*
AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundlandLabradorNova ScotiaOntarioPrince Edward IslandQuebecSaskatchewanNorthwest TerritoriesNunavutYukon

Postal Code*

Country*
CanadaUnited StatesUnited KingdomMexicoOther

Family Physician Contact*

Area of Concern*:
HandWristFootAnkleHipKneeElbowShoulder

Side Affected*
LeftRightBoth

When did the pain start?*

What do you attribute the pain to? If there has been a diagnosis, please provide as much information as possible.

Describe the pain:*
BurningAchingStabbingNumbnessCrampingThrobbingOther - will discuss at assessment

Does the Pain Radiate?*
NoYes, into left armYes, into right armYes into left legYes, into right leg

Check any of the following that reduce pain:*
RestIceHeatPain RelieversExerciseNone of the above

Check any of the following that make the pain worse:*
StandingWalkingBendingSittingStairsExerciseNone of the above

Check all that apply:*
Hospitalized in the past 5 yearsHistory of Malignancy (Cancer)Unexplained weight lossFeversChillsChange in bowl or bladder functionOsteoporosisDiabetesSmokingDrink Alcohol, more than 2 drinks per dayCortisone injection in the past 3 monthsNone of the above

Check any medications you are taking:*
AdvilAleveIbuprofenMotrinAspirinStatin (for high cholesterol)Blood thinnersNone of the above

Please any medications not listed above*:

Any treatments you have previously tried:*
ChiropractorPhysiotherapyMassageCortisone InjectionsAcupunctureNone of the above

Do you exercise?*
NoYes, MinimalYes, ModerateYes, Regular: 3-5 times per week

List any past surgeries*:

List any allergies, including latex*:

Do you have any other diagnosed conditions not mentioned above?*

I have answered the questions above and read and understand the following:
Payment PolicyPre-treatment Guidelines

Which of the following refers to you:*
I am an Albertan and my imaging reports are available on netcare.I am not an Albertan, and have faxed my imaging reports to (855) 878-9546

Submit