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Patient Intake Form


									                                   Patient Intake Form

First Name                           Middle Initial                       Last Name

Address                              City/Province                        Postal Code

Phone # (home)                       Phone # (work)                       Phone # (cell)

E-mail                               AHC #                                Date of Birth

Height/Weight          /             # of Children                             Male /    Female

Race       Afro-American        Am. Indian      Asian      Black    Caucasian   Hispanic/Other
Marital Status    Married        Divorced      Single      Separated    Widowed     Common-law

Occupation                                              Employer

                                             Reason for visit:
State area(s) of pain and mark on diagram below: 1.                            2.

Date pain or problem(s) started (onset):

Check one, if either applies:         Motor Vehicle Accident claim             Worker’s compensation claim
Which of the following caused your symptoms?
   Accident              Trauma             Sports Injury       Unknown factors
   Automobile accident          Work Injury               Aggravation of congenital problem

Have you had the same or similar complaint before?
   Never       1x         2x             3x        4x              > 4 times

Has the problem been getting better or worse since the onset?
   Improving           Getting worse           Comes and goes                       Stayed about the same

Describe in detail, how this complaint started:
                                                                Mode of Injury

Did your complaint begin gradually or suddenly?                                      Gradually…                          Suddenly…

Complete this section if your injury began GRADUALLY

Is your condition                          getting better                       getting worse                      remaining the same
What do you believe caused your condition?

Complete this section if your injury began SUDDENLY
This injury occurred when I…                                         Was your injury caused by an auto accident?                           Yes
                                                                                                                                            No
    awoke from sleep                                    was
                                                         involved in a accident                             Where were you when the injury occurred?
     bending and stood back up
     was                                                coughed or sneezed                                     outdoors                  playing sports
    slipped while carrying an object                   turned and looked to the side                          At work**                 while working
    climbed into or out of a vehicle                   twisted or turned at the waist                         home
     struck by a falling object
     was                                                 from a height
                                                         fell                                                   school
     engaged in a physical activity
     was                                                slipped and fell                                       At a business other than work
     engaged in a repetitive motion activity           lifted an object                               (store, restaurant…)
When did your pain or symptoms                      What type of pain did you feel immediately after the injury?          Was the injury reported to
begin?                                                                                                                    a supervisor?
    During the injury                                Dull ache                           Ripping/tearing sensation                    Yes
    Immediately after the injury                     Squeezing sensation                 Deep, boring pain                               No
    Several minutes after the injury                 Popping sensation                   Shock-like sensation
    Hours after the injury                           Localized, sharp pain               Pins & Needles sensation
    Days after the injury                            Sharp shooting pain                 Stabbing pain
                                                     Burning pain                        Numbness
Complete this section if your injury occurred WHILE LIFTING
Where were you lifting the object from?                   How much did the object weigh?                                  What was your position?
     floor
     the                                                      
                                                             < 2 pounds             15-20 lbs.                            Back was straight
     surface overhead
     a                                                       2-5 lbs.               20-25 lbs.                            Twisted to the left
     surface a about waist level
     a                                                       5-10 lbs.              25-30 lbs.                            Twisted to the right
                                                             10-15 lbs.             50+ pounds                            Bent at the waist
Complete this section if you were injured DUE TO A FALL
How far did you fall?             Did you hit any part of your body during the fall?                             What surface did you land on?
     feet
     2-4                                Head              elbow
                                                            Left                           knee
                                                                                           Left                      Concrete                  
     feet
     4-6                                Forehead          Right elbow                   Right knee                Pavement                  
     feet
     6-8                                Back               wrist/hand
                                                            Left                           ankle
                                                                                           Left                      Stairs                    
                                                                                                                                              Carpeted surface
    more than 8 feet                    hip
                                         Left              Right wrist/hand              Right ankle               Hard floor                
                                                                                                                                              Against a vehicle
    standing                                              Tailbone                                                 Deep water                
                                                                                                                                              Shallow water
What part of your body did you land on?
  Head          Left knee       Elbow                       Right side              Outstretched arms                Back
    Feet               Right knee          Shoulder           hip
                                                                  Left                    Outstretched left arm            Buttocks
    Knees              Stomach               side
                                               Left              Right hip               Outstretched right arm          Buttocks and back of thighs
Complete this if your injury was SUDDEN and NOT FROM A FALL OR LIFTING:
Describe in detail, the account of your injury:
                                                        Medical History
     Select all choices that apply to you and to your family (do not include relations by marriage).







 Abdominal pain                        Colitis                             Heart attacks                         Lung disease
 Allergies                             Convulsions                         Heart disease                         Multiple Sclerosis
 Angina                                Detached retina                     High blood pressure                   Osteoporosis
 Anorexia                              Diabetes                            HIV/AIDS                              Painful urination
 Aortic aneurysm                       Dislocated joints                   Irreg. Bowel                          PMS
 Arthritis*                            Dizziness                           Irreg. Menstrual                      Polio
 Asthma                                Emphysema                           Irritable colon                       Profuse menses
 Blood disorder                        Epilepsy                            Kidney disease                        Prostate disease
 Breast soreness                       Fainting                            Kidney stones                         Rapid heart rate
 Bulimia                               Hay fever                           Liver disease                         Rheumatic fever
 Cancer                                Headaches                           Low blood pressure                    Scoliosis
 Sex. trans. disease                   Sickle cell anemia                  Sinus trouble                         Spinal disc disorder
 Thyroid disorder                      Tuberculosis                        Ulcer                                 Vaginal discharge
 Stroke                                Other

    *Arthritis type:

 Are you currently seeing a Medical Doctor, Doctor of Chiropractic or Physiotherapist?
   No                  Yes, I see a MD / DC / Physiotherapist                   Doctor/Clinic Name:

If yes, has it helped your condition?              no             very little           moderately                  greatly

What does help your condition?

 List your surgical and hospitalization history.

   Past Surgical History                                                   Past Hospitalizations
   Date:                                                                   Date:
   Type of Surgery:                                                        Cause of Hospitalization:
   Where:                                                                  Complications/remaining problems:
   Complications/remaining problems:

 List your previous medical treatment and diagnostic tests. For example: Plain X-rays / CT Scan / MRI
/ EMG / Myelogram / Discogram / Thermogram / Bone Scan / Blood & Urine Chemistries / Other




   Facility tests performed:

   Area of Body:

                                                Health and Lifestyle

Do you eat dairy products?                Yes       No               Are you a vegetarian?                Yes         No
Do you often feel hypoglycemic (low blood sugar)?              Yes       No
Do you feel the need to eat when depressed or do you binge eat?                   Yes           No
How many meals a day do you eat?
   1               2                                3                             4                       more than 4

How often do you eat a well-balanced diet?
   Never                     Rarely                          Occasionally                       Usually             Always

How many bowel movements do you have a day?
   none           1               2                                     3 or more

Do you suffer from any of the following?
   Cramps            Gas or bloating                Gastro-intestinal pain                      Nausea

How much coffee do you drink per day?
   Zero             less than 1                     1-2                           3-4                     more than 5

How much soda pop or carbonated beverages do you drink per day?
   Zero            less than 1              1-2                                   3-4                     more than 5

How often do you consume alcohol?
   Never                    Rarely                           Occasionally                       Usually             On weekends

Do you smoke or chew tobacco?                No             In the past, for            years                       Yes, for           years
If yes:            Cigarettes             Cigars            Chewing tobacco

How much do you smoke?
   <5             5-10                    10-15              1 pack               2 packs                 3 or more

How many hours do you sleep per night?
   1         2            3                     4          5                  6             7                   8           9           10+

How do you sleep?
   back              side                 stomach                       combination

Do you feel chronically tired?
   Never                       Rarely                        Occasionally                       Usually             Always

Do you exercise (at least 30 minutes of activity 3-4 times per week)?
   Never                      Rarely                      Occasionally                          Usually             Always

Do you use drugs for recreational use? (optional to answer)
   Never                      Rarely                     Occasionally                           Usually             Always

Do you travel internationally?
   Never                       Recently                      Occasionally                   In the past

Do you have any allergies?
   None              Dust                           Latex                         Pollen                            Dairy products
   Penicillin        Sulfa drugs                    Perfumes                      Tobacco smoke                     Animal dander

Do you currently take medication?
   No prescription medications        No non-prescription med.        Blood thinner (i.e. aspirin)                        Muscle relaxer
   Anti-depressants             Anti-inflammatory       Pain medication         Blood pressure med                             Tranquilizers
   Birth control       Vitamin supplements              Other . . . .

Do (or did) you have any infections due to surgery, dental conditions or sinus troubles?                            Yes                 No

For woman only:
Are you pregnant or is there a possibility of you being pregnant?                 Yes           No   Due date
Are you lactating/breastfeeding ?                                                 Yes           No
                                                                       PLEASE ENSURE THAT
                                                                       YOUR SIGNATURE IS

                Informed Consent To Chiropractic Treatment
There are risks and possible risks associated with manual therapy techniques used by doctors of
chiropractic. In particular you should note:

a) While rare, some patients may experience short term aggravation of symptoms or muscle and
   ligament strains or sprains as a result of manual therapy techniques. Although uncommon, rib
   fractures have also been known to occur following certain manual therapy procedures;

b) There are reported cases of stroke associated with visits to medical doctors and chiropractors.
   Research and scientific evidence does not establish a cause and effect relationship between
   chiropractic treatment and the occurrence of stroke rather, recent studies indicate that patients
   may be consulting medical doctors and chiropractors when they are in the early stages of a
   stroke. In essence, there is a stroke already in progress. However, you are being informed of
   this reported association because a stroke may cause serious neurological impairment or even
   death. The possibility of such injuries occurring in association with upper cervical adjustment is
   extremely remote;

c) There are rare reported cases of disc injuries following cervical and lumbar spinal adjustment
   although no scientific study has ever demonstrated such injuries are caused, or may be caused,
   by spinal adjustments or chiropractic treatment.

d) There are infrequent reported cases of burns or skin irritation in association with the use of some
   types of electrical therapy offered by some doctors of chiropractic.

I acknowledge that I have discussed, or have had the opportunity to discuss, with my chiropractor
the nature and purpose of chiropractic treatment in general, (including spinal adjustment) the
treatment options and recommendations for my condition, and the contents of this Consent.

I consent to the chiropractic treatment recommended to me by my chiropractor, including any
recommended spinal adjustments.

I intend this consent to apply to all my present and future chiropractic care.

Dated this __________ day of ____________, 20_______.

_______________________________                           _______________________________
Patient Signature (Legal Guardian)                        Witness of Signature

Name: _________________________                           Name: _________________________
(please print)                                            (please print)
                                      Cancellation Policy


The purpose of this policy is to encourage awareness that missed appointments have an impact on
the physician’s, therapists’ and patients’ schedules. Arranging appointments according to prescribed
treatment plans assists both patient and practitioner in achieving optimal healing goals in a quicker


Soft Health and Healing Clinic requires 24 hours notice if an appointment is to be missed. Less than
24 hours notice will result in a cancellation fee equal to the treatment fee.

I understand the above stated Cancellation Policy and give consent to Soft Health and Healing Clinic
to charge my account for any missed appointments without 24 hours notification.



                               Thank you for your understanding.

                                       THE “50% RULE”

             The chiropractic physician is seeking 50% relief of pain
                     (measured subjectively and objectively)
                             within 30 days of care.

                              TYPICAL PATIENT OUTCOMES

              Median number of days to maximum improvement: 29
              Median number of visits to maximum improvement: 12

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