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250-462-4776 #166-290 Riverside Dr. Penticton, BC, V2Y 5Y5 www.nuvistachiropractic.com INTAKE FORM Name: Birthdate: Address: Name Phone: (home) Birthdate (month/day/year) (cell) Address Email: Postal Code: Occupation: How did you hear about us? ☐ Friend: ☐ Other professional: Extended Benefits Provider: Care Card #: (month / day / yea I would like: ☐ email reminders Postal Code ☐ text message reminders ☐ phone call reminders How did you hear about our clinic? □Friend: □Yellow Pages □Sign □Website ☐ Website ☐ Facebook□Other: Do ☐ you currently wear orthotics? □Yes □No Other: Are you interested in gait analysis? ICBC or WCB Claim? ☐ Yes ☐ No □Yes □No Claim #: CURRENT CONDITION: CURRENT CONDITION: Please de What brings you into the office today? How long When did it start? Have you What mak Is it getting?: ☐ Better ☐ Worse Have you had this before?: ☐ Yes ☐ No When? What mak W List any other professionals seen for this: Does this Wor When do your symptoms affect you the most? Are you currently taking any medication or supplements?: Please list: Do you have any allergies?: What are your goals for treatment?: CURRENT PREGNANCY: How far along are you in your pregnancy? ! Due Date? Have you experienced issues with fertility or miscarriage? ☐ Yes ☐ No Childbirth caregivers (circle): OB/GYN Last visit with caregiver: Midwife Doula: Any concerns?: Are you planning on having your baby: ☐ In hospital ☐ At home ☐ Other: Are you currently taking any medication or supplements?: Please list: Have you ever, or have you currently experienced any of the following during pregnancy?: ☐falls/trauma seizures ☐ MVA ☐ high blood pressure ☐ heart problems ☐ diabetes ☐ back/hip/groin pain ☐ hospitalizations ☐ trouble sleeping ☐ anemia ☐ ☐ abnormal bleeding ☐ headaches/neck pains ☐ any other illness or concerns (describe): Are you currently exercising or doing any other activities?: Are you currently working?: PREVIOUS PREGNANCIES: How many pregnancies have you previously had?: p: 250.448.8008 f: 250.448.7428 Did you experience any complications during the delivery?: 565 Osprey Avenue Any emergency care needed? Kelowna, BC V1Y 5A7 www.kelowna-chiro.com HEALTH HISTORY AND INFORMATION: PERSONAL HEALTH HISTORY -that The following a variety Please of conditions Y - The following lists a variety of conditions that patients experience. read that patients m Please check any conditions/symptoms apply tomay you:lists through the that list and check x next to each condition applies to the you.box next to each condition that applies to you. GENERAL CURRENT CONDITIONS DIAGNOSED CONDTIONS DIAGNOSED CONDTIONS SPECIFIC PAIN IN THE BODY □ Difficulty swallowing because of neck □ pain Born with bone or joint disorder □ Osteoporosis □ Pain or electric shocks in arms or legs □ when Degenerative arthritis/Osteoarthritis moving neck □ Rheumatoid arthritis □ Leg pain worse with exercise Compression fracture □□ Numbness of inner thighs □ Heart attack or heart disorder □□ Back pain with urinary problems History of stroke or aneurysm □□ Severe pain that interrupts sleep Cancer □□ Constant pain that doesn’t improve by Diabetes changing positions or by lying down □ Gout □ Lupus □ Ankylosing spondylitis SPECIFIC CURRENT CONDITIONS □ Immune suppression treatment or disorder from chemotherapy, organ □ Poor balance transplant, etc. □ Loss of boweldrug, or bladder control □ 3 or more steroid □ Blurred or doublemonths vision, of dizziness, SPE □ Recent accident as a fall, □ □ Born with bone or joint such disorder whiplash, or blow to the head □ □ Osteoporosis Spinal/back/neck problems □ □ Degenerative arthritis/Osteoarthritis Muscle spasms □ □ □ Rheumatoid arthritis □ Restricted movement □ □ Compression fracture Numbness orheart tingling of hands or feet □ eet □ □ Heart attack or disorder or radiating pain □ □ History of stroke or aneurysm □ Headaches or Migraines □ □ Cancer □ Sinus problems □ Diabetes Nausea □ □ Gout □ Depression □ Lupus Anxiety orspondylitis difficulty with stress SPE □ □ Ankylosing □ Dizziness or vertigo □ Immune suppression treatment or □ □ disorder Vision problem from chemotherapy, organ □ □ transplant, Hearing problem drug, etc. □ Sleeping trouble □□ 3 or more months of steroid medications or intravenous drugsis(past □ medications Asthma or breathing problem nausea or faintness when neck in or intravenous drugs (past □ or Digestive trouble or present) certain positions present) □ Heartburn/Acid Reflux Tuberculosis □□ Memory loss after injury □□ Tuberculosis □ Menstrual problems Hepatitis B or HIV infection □□ Recent, unexplained weight loss □□ Hepatitis B or HIV infection □ Jaw or mouth problem Multipleprogressive sclerosis muscle weakness □□ Recent □□ Multiple sclerosis Arm, shoulder, elbow or hand problem □ orThyroid shakingor hormone disorder em □□ Thyroid or hormone disorder □ □ Leg, hip, knee or foot problem □ High pressure □ Recentblood or current fever over 102°F □ High blood pressure □ Convulsions/epilepsy □ Convulsions/epilepsy □ OTHER: □ OTHER: Describe anybeen surgeries / hospitalizations / motor vehicle accidents / sporting accidents / pe Have you ever diagnosed with a accidents medical condition? (describe) alizations / motor vehicle accidents / sporting / personal/work accidents / fractures / dislocations / & / or illnesses you’ve had and the dates: nesses you’ve had and the dates: fall, Please describe any serious trauma/ accidents/ injuries/ surgeries/ hospitalizations? Please list any Medications you presently take AND what condition you are taking th u presently take AND what condition you are taking them for: Have you ever had any other health concerns? (describe): Have you had chiropractic care before: ☐ Yes ☐ No Current supplements and Why you are taking them: you are taking them: Are you exercising or performing any physical activities? Known Allergies (including medications, foods, seasonal, oils and lotions, etc.) dications, foods, seasonal, oils and lotions, etc.) ________________________________________________________________________ ______________________________________________________________________ YOUR LIFESTYLE How would you describe your sleep habits? How would you describe your diet? Any other concerns or issues we should be aware of?: Please Note: Your appointment time has been reserved for you. In courtesy of your therapist and fellow patients, we ask that you provide us with 12 hours notice of cancellation, or a cancellation fee will be charged. Payment for all treatment, whether private or insured, is ultimately the responsibility of the patient. I authorize the clinic and its associated practitioners to collect my personal and medical information as documented above in order to contact me, and I give the clinic permission to leave messages regarding appointments at any of the contacts I have provided above. In addition, I authorize the clinic and its associated practitioners to communicate with my referring MD as deemed necessary for my benificial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission. Signature: Date: