Chiropractic Intake Form

Name

First Name Last Name
Contact Information

Phone Number Email (example@example.com)
Address

Street Address

City

Postal / Zip Code
Date of Birth

Date (DD)

Month (MM)

Year (YYYY) Age

Gender
Height and Weight

Height Weight
Occupation:
Family Physician

Family Physician Name

Family Physician Address
How did you hear about us?
Extended Health Benefits
Do you have health insurance?

Yes No
Does your spouse of health insurance?

Yes No
Spousal Date of Birth

Day (DD)

Month (MM)

Year (YYYY)
Health Insurance Information

Insurance Provider

Plan/Policy Number

Member ID
Sign Here:

Clear
Please indicate where the pain is located
Front of Body - Right Side

Forehead Collarbone Chest Bicep Elbow Wrist Hand Hip Thigh Knee Shin Ankle Foot
Front of Body - Left Side

Forehead Collarbone Chest Bicep Elbow Wrist Hand Hip Thigh Knee Shin Ankle Foot
Side of Body - Right Side

TMJ Neck Shoulder Ribs Hip Thigh Knee Calf Ankle Foot
Side of Body - Left Side

TMJ Neck Shoulder Ribs Hip Thigh Knee Calf Ankle Foot
Back of Body - Right Side

Head Neck Shoulder Triceps Wrist Hand Mid back Lower back Glutes Hamstring Knee Calf Heel
Back of Body - Left Side

Head Neck Shoulder Triceps Wrist Hand Mid back Lower back Glutes Hamstring Knee Calf Heel
When did this pain begin?
Was this pain from a:

Work Injury Auto Accident
Is this pain getting:

Better Worse
Does this pain occur

All Day Comes & Goes
Do you experience pain when you cough?

Yes No
What is the quality of pain?

Sharp Dull Achy Stabbing Shooting
Severity of Pain

0 (no pain) 1 2 3 4 5 6 7 8 9 10 (severe)
When is the pain better?

Morning Afternoon Evening Night All Day
When is the pain worse?

Morning Afternoon Evening Night All Day
Does the pain travel to different parts of the body?

Yes No
Are you experiencing numbness or tingling sensations?

Yes No
What makes the pain better?
What makes the pain worse?
Who have you seen for this condition:

Family Doctor Chiropractor Massage Therapist Physiotherapist Acupuncturist Chiropodist Specialist Other
Do you or your immediate family have any of the following conditions?

Cancer Diabetes Heart Disease Arthritis Osteoporosis High BP Stroke
Are you on any medication?

Yes No
Have you been diagnosed with any medical conditions?

Yes No
Have you had any surgeries?

Yes No
Have you fractured or dislocated any bones?

Yes No
Have you had a physical exam over the past 12 months?

Yes No
Have you been in an auto accident in the past 2 years?

Yes No
Have you been admitted to a hospital before?

Yes No
Have you had any major slips or falls?

Yes No
Are you experiencing any muscle weakness?

Yes No
Have you experienced any abnormal gain or loss in weight recently?

Yes No
Does the pain wake you up at night?

Yes No
Are you experiencing night sweats?

Yes No
Are you experiencing any swelling?

Yes No
Has the pain prevented you from working?

Yes No
Have you had this condition previously?

Yes No
Do you play any contact sports (football, hockey, etc.)?

Yes No
Do you have a family history of this condition?

Yes No
Have you had x-rays in the past five years?

Yes No
Have you had an MRI in the past five years?

Yes No
Have you been prescribed orthotics?

Yes No
Are you a smoker?

Yes No
Are you physically active?

Yes No
WOMEN ONLY - Are you pregnant?

Yes No
Please rate your stress level:

0 (No Stress) 1 2 3 4 5 6 7 8 9 10 (Severe)
To what extent has this condition affected your daily life?

0 (None) 1 2 3 4 5 6 7 8 9 10 (Severe)
How motivated are you towards treatment of your pain condition?

0 (Not Motivated) 1 2 3 4 5 6 7 8 9 10 (Considerably Motivated)
YOUR PRIVACY IS OUR PRIORITY
Patient Consent Form For Collection, Use and Disclosure of Personal Information
In this office, for their respective patients, Dr. Faisal Malik acts as the Privacy Information Officer. All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate use and protection of your information. Attached to this consent form, we have outlined what our office is doing to ensure that: Only necessary information is collected about you; Information is shared only with your consent; Storage, retention and destruction of your personal information complies with existing legislation, and privacy protection protocols; Our privacy protocols comply not only with privacy legislation, but with the standards of the Ontario Chiropractic Association, and the law. Do not hesitate to discuss our policies with Dr. Faisal Malik or any member of our office staff. Please be assured that every staff member in our office is committed to ensuring that you receive the best quality health care. This office will collect, use and disclose information about you for the following purposes: To offer and provide treatment, care and services for all chiropractic health care issues. To deliver safe and efficient patient health care and to identify and ensure continuous high quality service. To assess your health care needs and to advise you of treatment options. To enable us to contact you and maintain communication with you, for purposes of distributing health care information and booking/confirming appointments for treatments. To maintain communication with you through email newsletters. To invoice for goods and services, to process credit card payments, and to collect on unpaid accounts. To communicate with other treating health care providers, including your pharmacist/pharmacy. To communicate with laboratories in cases where laboratory services are required. For teaching and demonstrating purposes on an anonymous basis. To complete and submit chiropractic claims for third party adjudication and payment. To comply with legal and regulatory requirements, including the delivery of patients’ charts and records to the Ontario Chiropractic Association in a timely fashion, when required, according to the provisions of the Personal Health Information Protection Act (PHIPA) . To comply with agreements/ undertakings entered into voluntarily by the member with the Ontario Chiropractic Association, including the delivery and/or review of patients’ charts and records to the Association in a timely fashion for regulatory and monitoring purposes. To deliver your charts and records to the Chiropractic insurance carrier to enable the insurance company to assess liability and quantify damages, if any. To assist this office to comply with all regulatory requirements and to comply generally with the law By signing the consent section of the Patient Consent Form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in advance. Your information may be accessed by regulatory authorities under the terms of the Personal Health Information Protection Act (PHIPA) for the purposes of the Ontario Chiropractic Association fulfilling its mandate under the PHIPA, and for the defence of a legal issue. Our office will not, under any condition, supply your insurer with your confidential medical history. In the event that this kind of a request is made, we will forward the information directly to you for review, and for your specific consent. When unusual requests are received, we will contact you for permission to release such information. We may also advise you if such a release is inappropriate. You may withdraw your consent for use or disclosure of your personal information at any time, and we will explain the ramifications of the decision, and the process.
Patient Consent
I have reviewed the Privacy Policy that explains how this office will use my personal information, and the steps this office is taking to protect my information. I know that this office has a Privacy Policy, and I can ask to see the Policy at any time. I agree that Dr. Faisal Malik and his staff can collect, use and disclose personal information about myself as set out in the attached information about the office’s privacy policies.
Signature:

Clear
Date DD/MM/YYYY):

Day Month Year
Date
Electronic Transmission Authorization and Consent Form

Instructions: This form must be filled out when claims are submitted electronically by the provider on the patient’s behalf. Please retain this form in the patient’s file for verification purposes for two years following closure of the patient file.

Provider: Canadian Muscle and Joint Pain Clinic Inc. 4-5980 Churchill Meadows Blvd, Mississauga L5M 7M5
Patient Name

First Name Last Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Plan and Certificate Number

Plan Number Certificate/Plan Member Number
Consent to Collect and Exchange Personal Information Message to the Plan member, Spouse and/or Dependent regarding Personal Information

Personal information that we collect and disclose about you, and if applicable, your spouse and/or dependents, is used by the insurer and/or plan administrator and their service provider(s) for the purposes of assessing your claims, underwriting, investigating, auditing and administering the group benefits plan, including the investigation of fraud and/or plan abuse.
Authorization and Consent
- I authorize my healthcare provider to collect, use and disclose personal information concerning any claims submitted on my behalf with the insurer and/or plan administrator and their service provider(s) for the above purposes. I authorize the insurer and / or plan administrator and their service provider(s) to:
- use my personal information for the above purposes.
- exchange personal information with any individual or organization, including healthcare professionals, investigative agencies, insurers and reinsurers, and administrators of government benefits or other benefits programs when relevant for the above purposes.
- exchange personal information concerning any claims submitted with the plan member or a person acting on behalf of the plan member.
- exchange personal information for the above purposes electronically or in any other manner. I understand that personal information may be subject to disclosure to those authorized under applicable law. I agree that a photocopy or electronic version of this authorization shall be as valid as the original, and may remain in effect for the continued administration of the group benefits plan.
Additional Consent Applicable to Plan Members Only
I confirm that I am authorized by my spouse and/or dependents, if any, to disclose personal information about them to the insurer and/or plan administrator and their service provider(s) for the purposes described above and I confirm that my spouse and/or dependents also authorize the insurer and/or plan administrator and their service provider(s) to disclose information about their claims to me, for the purposes of assessing and paying a benefit, if any, and managing the group benefits plan. I also authorize my spouse and/or dependents to assign benefit payments under the plan to the healthcare provider. In the event there is suspicion and/or evidence of fraud and/or plan abuse concerning claims submitted, I acknowledge and agree that the insurer and/or plan administrator and their service provider(s) may use and disclose relevant personal information to any relevant organization including law enforcement bodies, regulatory bodies, government organizations, medical suppliers and other insurers, and where applicable my Plan Sponsor, for the purposes of investigation and prevention of fraud and/or plan abuse. If there is an overpayment, I authorize the recovery of the full amount of the overpayment from any amount payable under the group benefits plan, and the exchange of personal information with other persons or organizations, including credit agencies and, where applicable, my Plan Sponsor, for that purpose.
Patient Name

First Name Last Name
Date:

Day Month Year
Date
Signature:

Clear
Informed Consent for Chiropractic Examination and

Chiropractic is the treatment and prevention of disorders of the joints of the body, often the joints of the spine, and the structures, which are related to joint function, including muscles, ligaments, tendons and nerves. Chiropractors use a variety of methods for diagnosis. These methods include taking a full history, as well as the history related to the presenting complaint and conducting a physical examination. A thorough history and examination also helps to determine the need for referral to another health professional and to determine if there are any contraindications to certain treatment procedures.

The physical exam will focus on the area of chief complaint, as well as other areas, which may be having an impact on that region or may be capable or referring pain to the area. The examination may include observation, ranges of motion, palpation (the use of one’s hands in the assessment), neurological examination and orthopaedic testing. Other tests may be performed or recommended, as deemed necessary by the treating chiropractor.

The physical examination will necessitate physical contact between the doctor and the patient. As with many physical examination procedures, it may be necessary to repeat the chief complaint in order to make an accurate diagnosis; you may be asked to perform tests that may be uncomfortable or which may aggravate your condition in the hours to days following an examination. This is normal. If you feel uncomfortable at any time, during the examination or following a chiropractic visit please notify the doctor. Following your physical examination, the chiropractor will make a differential diagnosis, provide a customized treatment plan and discuss informed consent for treatment.
Patient or Parent/Guardian Name
Patient or Parent/Guardian SIGNATURE

Clear
Date

Day Month Year
Date
Dr Faisal Malik - Chiropractor Lic 5849 Dr Rosanna Cheng - Chiropractor Lic 7177
CONSENT TO CHIROPRACTIC TREATMENT
It is important for you to consider the benefits, risks and alternatives to the treatment options offered by your chiropractor and to make an informed decision about proceeding with treatment. Chiropractic treatment includes adjustment, manipulation and mobilization of the spine and other joints of the body, soft-tissue techniques such as massage, and other forms of therapy including, but not limited to, electrical or light therapy and exercise.
Benefits
Chiropractic treatment has been demonstrated to be effective for complaints of the neck, back and other areas of the body caused by nerves, muscles, joints and related tissues. Treatment by your chiropractor can relieve pain, including headache, altered sensation, muscle stiffness and spasm. It can also increase mobility, improve function, and reduce or eliminate the need for drugs or surgery.
Risks
The risks associated with chiropractic treatment vary according to each patient’s condition as well as the location and type of treatment.

The risks include:
- Temporary worsening of symptoms – Usually, any increase in pre-existing symptoms of pain or stiffness will last only a few hours to a few days.
- Ski n irri t ation or bur n – Skin irritation or a burn may occur in association with the use of some types of electrical or light therapy. Skin irritation should resolve quickly. A burn may leave a permanent scar.
- Sprain or strain – Typically, a muscle or ligament sprain or strain will resolve itself within a few days or weeks with some rest, protection of the area affected and other minor care.
- Rib fracture – While a rib fracture is painful and can limit your activity for a period of time, it will generally heal on its own over a period of several weeks without further treatment or surgical intervention.
- Injury or aggravation of a disc – Over the course of a lifetime, spinal discs may degenerate or become damaged. A disc can degenerate with aging, while disc damage can occur with common daily activities such as bending or lifting. Patients who already have a degenerated or damaged disc may or may not have symptoms. They may not know they have a problem with a disc. They also may not know their disc condition is worsening because they only experience back or neck problems once in a while.
Chiropractic treatment should not damage a disc that is not already degenerated or damaged, but if there is a pre-existing disc condition, chiropractic treatment, like many common daily activities, may aggravate the disc condition.

The consequences of disc injury or aggravating a pre-existing disc condition will vary with each patient. In the most severe cases, patient symptoms may include impaired back or neck mobility, radiating pain and numbness into the legs or arms, impaired bowel or bladder function, or impaired leg or arm function. Surgery may be needed.
- Stroke – Blood flows to the brain through two sets of arteries passing through the neck. These arteries may become weakened and damaged, either over time through aging or disease, or as a result of injury. A blood clot may form in a damaged artery. All or part of the clot may break off and travel up the artery to the brain where it can interrupt blood flow and cause a stroke.
Many common activities of daily living involving ordinary neck movements have been associated with stroke resulting from damage to an artery in the neck, or a clot that already existed in the artery breaking off and travelling up to the brain.

Chiropractic treatment has also been associated with stroke. However, that association occurs very infrequently, and may be explained because an artery was already damaged and the patient was progressing toward a stroke when the CCPA 09.14 Page 1 of 2 patient consulted the chiropractor. Present medical and scientific evidence does not establish that chiropractic treatment causes either damage to an artery or stroke.

The consequences of a stroke can be very serious, including significant impairment of vision, speech, balance and brain function, as well as paralysis or death.
Alternatives
Alternatives to chiropractic treatment may include consulting other health professionals. Your chiropractor may also prescribe rest without treatment, or exercise with or without treatment..
Questions or Concerns
You are encouraged to ask questions at any time regarding your assessment and treatment. Bring any concerns you have to the chiropractor’s attention. If you are not comfortable, you may stop treatment at any time.

Please be involved in and responsible for your care. Inform your chiropractor immediately of any change in your condition.
DO NOT SIGN THIS FORM UNTIL YOU MEET WITH THE CHIROPRACTOR
Should be Empty:

Extended Health Benefits

Please indicate where the pain is located

YOUR PRIVACY IS OUR PRIORITY

Patient Consent Form For Collection, Use and Disclosure of Personal Information

Patient Consent

Authorization and Consent

Additional Consent Applicable to Plan Members Only

CONSENT TO CHIROPRACTIC TREATMENT

Benefits

Risks

Alternatives

Questions or Concerns

DO NOT SIGN THIS FORM UNTIL YOU MEET WITH THE CHIROPRACTOR