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Intake Form

If you still have questions please contact us directly.

About You

Your name*

Your email*

Phone Number*

Gender*
femalemaleother

Date of Birth*

Address*

City*

Province*

Postal Code*

Country*

Emergency Contact

Emergency Contact Name*

Relationship to you*

Emergency Contact Home Phone*

Emergency Contact Mobile Phone*

Medical History

Family Physician*

Family Physician Clinic Name*

Family Physician Contact*

Personal History*:
High Blood PressureStrokeOsteoporosisMigrainenone

Other

Family History*:
High Blood PressureStrokeOsteoporosisMigrainenone

Check all that apply:*
Hospitalized in the past 5 yearsHistory of Malignancy (Cancer)Unexplained weight lossFeversChillsChange in bowel or bladder functionOsteoporosisDiabetesSmokingAlcohol, occasionalAlcohol, more than 2/dayCortisone injection in the past 3 monthsNone

Do you exercise?*
NoYes, OccasionalYes, ModerateYes, Regularly

List any past surgeries*:

List any allergies, including latex*:

Do you have any other diagnosed conditions not mentioned?*

Concerns

Area of Concern*:
HandWristFootAnkleHipKneeElbowShoulder

Side Affected*
LeftRightBoth

Can you explain your concern?

Symptoms

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.*

How quickly do symptoms appear?*:
SuddenGradualChronic

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

How does the pain feel?*:
DullSharpElectricTingling

What makes the pain worse?*:

How long does the pain last?*:

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

Treatment History

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

Please list any medications not listed above:

Any treatments you have previously tried:*
ChiropractorPhysiotherapyMassageHeatIceBracingTylenolMuscle RelaxantsCortisone InjectionsSteroid InjectionAnti-InflammatoriesPrescription MedicationViscosupplementationMigraine MedicationSpinal DecompressionAcupunctureNone of the above

Previous Diagnostics:*
UltrasoundX-rayCT ScanMRIBone ScanNone

I have answered the questions above and read and understand the following:*
Payment Policy
Pre-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) 878-9273.

Joint Rejuvenation & Spine Intake Form

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About You

Emergency Contact

Medical History

Concerns

Symptoms

Treatment History

Clinic Address

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Services

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About You

Emergency Contact

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Symptoms

Treatment History

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