Patient Intake Form

Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Care Card Number:
MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone:*

Area CodePhone Number
Mobile:

Area CodePhone Number
E-mail:*
(Your email will be used for appointment reminders only)
Occupation:
Emergency Contact:*
Relationship to you:
Phone:*

Area CodePhone Number
Mobile:

Area CodePhone Number
Current Medications:
Allergies:
Reason for Visit
JobAuto AccidentFallChronic DiscomfortSports InjuryWellness CareDoctor ReferralOther
YesNo
If yes, please complete the following:
Date of Accident:

MonthDayYear
ICBC Claim#:
Adjustor’s Name:
Phone:

Area CodePhone Number
Current Condition
Briefly describe your current condition and symptoms:*
How long have you had this condition?*
Describe what aggravates the condition?*
Describe what relieves the condition?*
WorseBetterSame
WorkSleepDaily RoutineOther
ChiropractorPhysiotherapistMassage TherapistAcupuncturistOther
Date of last treatment:

MonthDayYear
YesNo
Please describe where you experience pain, discomfort, altered sensation, or weakness:*
Health History

Please indicate if you have any of the following, past or present:
NoneDizzy SpellsMigrainesSeizuresDementiaAcquired Brain InjuryTIAStrokeParalysisDisc HerniationNerve CompressionOther
YesNoOther
NonePalpitationsArrhythmiaHeart FailureHypertensionMIPeripheral EdemaAngioplastyValve ReplacementPacemakerOther
NoneAnemiaVTEDVTOther
NoneAsthmaCOPDObstructive Sleep ApneaCPAPTuberculosisOther
NoneGERD (reflux)UlcersHepatitisLiver DiseaseCrohn’sColitisOstomyOther
NoneRenal DiseaseDialysisUrostomyOther
NoneEczemaPsoriasisShinglesWoundsOther
NoneOsteoarthritisOsteoporosisAmputeeFracturesSprainStrainJoint ReplacementTendonitisBursitisDislocationOther
NoneMultiple SclerosisRheumatoid ArthritisHIVOther
NoneDiabetesPancreatitisThyroidOther
YesNo
Surgical History:
No deficitBlindMacular DegenerationGlaucomaGlasses
No DeficitDeafHearing Aids
YesNo
Consent & Payment Responsibility
Your appointment time has been reserved for you. In courtesy of your therapist and fellow patients, we kindly ask that you provide us with 24-hour notice of cancellation, or a cancellation fee of a full treatment fee will be charged.

Consent:

I authorize the clinic and its associated RMTs to collect my personal and medical information as documented above in order to contact me, and give permission for the clinic to leave messages regarding appointments at any of the contact numbers I have provided. In addition, I authorize the clinic and its associated RMTs to communicate with my referring MD as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.
Signature:*
(Please type name) If you are 18 years of age or younger, please have your guardian sign consent of treatment. We also request the guardian to be present during treatment.
Yes
Once you have completed the form and press the 'Submit" button, make sure you read "Thank you First, Last Name". If you do not see a thank you message, please scroll through the form and complete the fields highlighted in RED.
Should be Empty:

Reason for Visit

Current Condition

Health History

Consent & Payment Responsibility