Download Please use the diagram at right to indicate the following: Numbness

 INTAKE FORM PERSONAL INFORMATION Name:  Female  Male Care Card # Address: City: Province: Telephone: Home: Email: Occupation: Emergency contact: Name: Phone: Date: Postal Code: Work: Cell: Day Month Year Birth Date: Appointment reminder:  Email  Text message (Who is your cell phone provider? Bell, Rogers, etc.) How did you hear about us? Please use the diagram at right to indicate the following: Numbness: ==== Pins & Needles: oooo Burning: xxxxx Sharp/stabbing: sssss Dull/aching: >>>> Stiff/tight: 2222 Using the scale, please indicate the severity of your current pain by circling a number: 0 2 3 4 5 6 NO PAIN Reason for appointment: EXTREME PAIN When did this begin? How did this occur? Have you ever had similar problems?  Yes  No Has the condition 1 7 8 9 10  improved  worsened  remained unchanged since it began? Is this condition related to: Work?  Yes No Has your employer been notified?  Yes  No Motor vehicle accident? Yes  No Date of accident: Claim #: Adjuster: Patient Name: What have you done for condition? What have you done to this help with this condition? Date: Have you had X-­‐rays or oor ther tests (MRI, CT, blood work etc.) for w
this condition? Have you had X-­‐rays other tests (MRI, CT, Ultrasound, blood ork etc.) for this condition?  Yes  No Can you tests perform your daily What and w
hen? home activities? Yes Yes, only with h elp Can you perform your daily work activities? All activities Only some Can you perform your daily home activities?  Yes  Yes, only with help Describe your stress level: None/mild Moderate Can you perform your daily work activities?  All activities  Only some Do you exercise? Daily Occasionally Describe your stress level:  None/mild  Moderate Do ytou xercise? the way you feel  Daaily Occasionally Circle he ew
ord that best describes bout your g eneral health: Not at a ll Not at all  Not at all High  Not at all Not at all  High  Not at all Circle tExcellent he word t hat the way y ou your general health: b
Gest ood d escribes Acceptable Pfeel oor a bout Very poor a chieve Good f rom Atcceptable heck Poor aVpply. ery poor What do yExcellent ou hope t o his visit? C
all t hat What do Pyain Explanation our caondition ou rhelief ope to a chieve from this visit? o f Cyheck ll that apply.  Pain relief  Explanation of your condition  Performance care  Wellness/maintenance care Exercise to prevent recurrence  Exercise to prevent recurrence  Other: Body part(s): Details: Why? Doctor: Date: Date: Date: Date: Please list any previous surgeries, illnesses or injuries: Have you had any fractures or dislocations? Have you ever been in a car accident? Have you ever been hospitalized? Have you had previous chiropractic care?  Yes  Yes  Yes  Yes  No  No  No  No List all medications: (prescriptions, vitamins, herbal supplements, birth control, Aspirin, Advil, Tylenol etc.) List all known allergies: Have you or a family member ever been diagnosed with or told you have any of the following? High blood p ressure Hardening of the arteries Heart or blood disease Diabetes Tuberculosis Stroke Cancer Osteoporosis (low b one density) HIV/AIDS Hepatitis A/B/C Are you currently a smoker? Did you smoke previously? Average alcohol intake Average caffeine intake Current sleep quality  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  No  No  No  No  No  No  No  No  No  No  Family  Family  Family  Family  Family  Family  Family  Family  Yes  No Amount:  Yes  No Years: drinks/day coffee/tea/pop per day Poor 1 2 3 4 5 Good Patient Name: Date: HEALTH STATUS SURVEY Please circle any conditions that are presently causing you a problem and underline those that have caused you problems in the past. GENERAL SYMPTOMS Fever Excess sweating/night sweats Loss of consciousness Headache Fatigue Nervousness Weight loss Night pain Loss of sleep NEUROLOGICAL Visual disturbances (blurred, double) Dizziness Fainting Convulsions Problem speaking Problem swallowing Numbness or tingling Clumsiness Weakness EYES/EARS/NOSE/THROAT Failing vision Eye pain Failing hearing Earache Ring/buzz in ears Frequent colds Sinus infection Enlarged thyroid Enlarged glands Hoarseness Nasal drainage Nosebleeds SKIN Rashes Itching Dryness Easy bruising Boils Hives (allergies) Changes in moles or skin markings (size, color, borders, elevation, bleeding) GENITOURINARY Frequent urination Painful urination Blood in urine Kidney infection Prostate trouble Trouble starting flow Uncontrollable urine flow Bedwetting CARDIOVASCULAR RESPIRATORY High blood pressure Asthma Low blood pressure Chronic cough Bleeding disorder Spitting up phlegm Stroke Spitting up blood Hardened arteries Chest pain Heart/blood disease Wheezing Palpitations Difficulty breathing Angina Shortness of breath Poor circulation Swelling of ankles Varicose veins MUSCLE & JOINT Neck pain Back pain Tailbone pain Shoulder pain Arm/forearm/elbow pain Wrist/hand pain Hip/leg pain Knee pain Ankle/foot pain Swollen joints Spinal curvature Arthritis GENITOURINARY FOR WOMEN Painful menstruation Excessive flow Hot flashes Irregular/absent cycle Cramping/backache Vaginal discharge Nipple discharge Swollen Breasts Lumps in breast Menopausal symptoms Pregnancy complications/miscarriage Pregnant? Y / N Week? GASTROINTESTINAL Poor appetite Indigestion/heartburn Excess hunger Belching/gas Nausea/vomiting Constipation Diarrhea Hemorrhoids (piles) Blood in stool Gallbladder trouble Jaundice Ulcer WRITTEN CONSENT TO NOTIFY FAMILY PHYSICIAN OF CHIROPRACTIC CARE At Bluebird Sport & Spine, we strive to maintain open communication and professional relationships with other health care providers. In order to provide updates to your family doctor regarding your care, we need to obtain written consent from you as our patient. Please fill in the information below so we can inform your doctor about your diagnosis, treatment, and p rogress at our clinic. Dated this day of Family Physician’s Name: Patient Signature: Patient Name: (please print) , 20 . Phone: Witness Signature: Witness Name: (please print)