4
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 /4 1 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

Acupuncture Intake form-14June2018 · * We communicate appointment reminders, invoices, receipts, exercise programs & health tips via email. We hate spam, but we really value educational

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Page 1: Acupuncture Intake form-14June2018 · * We communicate appointment reminders, invoices, receipts, exercise programs & health tips via email. We hate spam, but we really value educational

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

Page 2: Acupuncture Intake form-14June2018 · * We communicate appointment reminders, invoices, receipts, exercise programs & health tips via email. We hate spam, but we really value educational

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

''''''''''''''

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================================================================================================================================

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(/:($)-#:(!)1$)!0#'!$+/!FhPPBD"SN!/?*/+-/:3-:7<! !

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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

Page 3: Acupuncture Intake form-14June2018 · * We communicate appointment reminders, invoices, receipts, exercise programs & health tips via email. We hate spam, but we really value educational

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:

Page 4: Acupuncture Intake form-14June2018 · * We communicate appointment reminders, invoices, receipts, exercise programs & health tips via email. We hate spam, but we really value educational

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