Osteopathy Form Medical Case History

					                                                          Osteopathy Form
                                                         Medical Case History
                                        12 Irwin Ave, Suite 200. Toronto, ON. M4Y 1K9 Phone: 416-926-8794

  The information on this form is confidential and will be used to assist your therapist in determining a treatment plan.

  Name:__________________________Telephone (work) ____________________ (home) _______________________

  Address: _______________________________City: ____________________Postal Code: _______________________

  Date of Birth: _____________ Weight: _______ Height: _______ Occupation: _________________________________

  Email address:____________________________________________________________________________________

  What brings you in for Treatment? ___________________________________________________________________________
  We regret we must charge for appointments missed or cancelled with less than 24 hours’ notice.
  We are not a Doctor of Osteopathy.

  With an X, indicate where you feel                             What is your chief complaint?
  your pain or discomfort

                                left          right              How long have you had it?



                                                                 When is the pain worse? Better?




       right           left


   Do you consent to receive treatment?
  Condition:                                                       Date:

  _________________________________________                        ____________________________________________


  _________________________________________                        ____________________________________________
  I agree to receive treatment.


  ___________________________
  Signature

For Office Use:                          Year
      File Updates:                      __________                __________                 __________
                                                 Patient Health History
    Please underline any conditions you are experiencing presently. Please check () conditions experienced in the past


   General
   Headaches                        Jaw pain / Bruxism                Poor circulation               Arthritis / Bone
   Fevers                           Genitourinary                     Hemophilia                     Osteoarthritis / RA
   Chills                           Frequent urination                Skin                           Osteoporosis
   Sweats                           Painful urination                 Eczema
   Fainting                         Blood in urine                    Itching                        Infectious Diseases
   Dizziness                        Kidney/Bladder infection          Bruises easily                 Chicken pox
   Loss of sleep                    Kidney stones                     Dryness                        Mumps / Measles
   Fatigue                          Bed wetting                       Boils                          Hepatitis A B C
   Nervousness                      Prostate trouble                  Sensitive skin                 HIV
   Allergies ________               Urinary tract infection           Varicose veins                 TB
   Numbing/tingling                 Incontinence                      Infectious skin condition      Other: _____________
   Epilepsy                                                              Type: _________
   Diabetes                         Respiratory                                                      Women’s Section
                                    Chronic cough                     Gastrointestinal               Painful menstruation
   Ear, Nose, Throat & Eyes         Spitting up phlegm                Poor / large appetite          Irregular cycle
   Failing vision                   Spitting up blood                 Difficult digestion            Cramps or backache
   Eye pain                         Chest pain                        Belching or gas                Irregular vaginal discharge
   Deafness / tinnitus              Difficult breathing               Nausea                         Swollen breasts
   Earache / Ear discharge          Smoking # yrs_______              Colon trouble/colitis          Painful breasts
   Nosebleeds                       Asthma                            Constipation or diarrhea       Lumps in breast
   Nasal obstruction                Bronchitis                        Liver / gallbladder trouble    Excessive flow
   Hoarseness                       Shortness of breath               Acid reflux / hiatus hernia    Premenstrual symptoms
   Sore throat                                                        Pain in stomach                Yeast infections
   Rhinitis                         Cardiovascular                    Hemorrhoids                    Fibroids _____
   Gum trouble / bleeding           Phlebitis                                                        Cysts _____
   Frequent colds                   Hx of heart attack / Stroke       Presence of:                   Miscarriage(s)
   Tonsillitis                      High / Low blood pressure         Pins                           Pregnancy, trimester ___
   Sinus infection                  Pain over heart                   Wires                          # of pregnancies___
   Nasal drainage                   Blocked arteries                  Artificial joints              Menopause
   Swollen glands                   Swelling of ankles                Special equipment

   Any other conditions: ________________________________________________________________________________

   Exercise: _____________________________________________________________________________________


Therapies Received               Injury History                Surgery History                      Family Health History
Massage Therapy ____             Injury:__________             Surgery:__________                   Circle if any one in your
Chiropractic_________            Date:___________              Date:____________                    family has/had the following?
Physiotherapy________
Acupuncture_________             Injury:__________             Surgery:__________                   Osteoporosis Osteoarthritis
Shiatsu_____________             Date:___________              Date:_____________                   Rheumatoid arthritis
Counseling__________                                                                                Cancer     Gout      TB
Reflexology _________            Injury:__________             Surgery:___________                  Diabetes
Other_______________             Date:___________              Date:______________                  Hypertension Heart Disease


Medications and/or Supplements

Name: _____________              Name: _____________              Name: _____________               Name: _____________

Condition: __________            Condition: __________            Condition: __________             Condition: __________

				
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posted:3/27/2012
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