Personal Information
First Name
*
Last Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Age
Marital Status
Please Select
Single
Married
Common Law
Divorced
Widowed
Gender
Female
Male
Number of Children
Family Doctor
Occupation
Contact Information
Address
*
City
*
Postal Code
*
Cell or Home Phone #
*
-
Area Code
Phone Number
Work Phone #
-
Area Code
Phone Number
E-Mail
*
How did you hear about our clinic? (Check one):
Family Member
Friend or Co-Worker
Health Care Professional (eg. Physician, Physiotherapist, Massage Therapist, etc.)
Internet Search
Social Media
Other
Please let us know who we can thank for referring you to our office:
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Reason for Consulting
What is your primary reason for consulting today? (check all that apply)
Shoulder pain
Elbow pain
Wrist / hand pain
Hip pain
Knee pain
Ankle / heel / foot pain
Other
Side affected:
Right
Left
Both
Nature of the Problem
Which best describes your concern? (check all that apply)
Joint pain
Tendon pain (tendinitis / tendinopathy)
Bursitis
Stiffness or reduced mobility
Arthritis / wear-and-tear
Heel pain / plantar fasciitis
Other
Symptom History
How long have you had this issue?
< 6 weeks
6 weeks–3 months
3–6 months
> 6 months
Onset was:
Gradual
After injury or overuse
Unsure
Pain & Functional Impact
Current pain level (0 = least, 10 = worst):
0
1
2
3
4
5
6
7
8
9
10
Least
Worst
0 is Least, 10 is Worst
What activities make your symptoms worse? (check all that apply)
Walking
Stairs
Lifting
Reaching overhead
Gripping
Standing
Exercise/Sport
Daily activities
Sleep
Previous Care for This Issue
Have you tried any of the following? (check all that apply)
Chiropractic
Physiotherapy
Massage therapy
Injections
Medications
Orthotics/Braces
None
Did this provide lasting relief?
Yes
No
Temporary
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Relevant Medical History
Please check all that apply:
Osteoarthritis
Rheumatoid or inflammatory arthritis
Diabetes
Osteoporosis / low bone density
Bleeding or clotting disorder
Neuropathy or nerve condition
Circulatory or vascular disease
Previous fracture in this area
Previous surgery on this joint
None of the above
Approx. date of surgery:
Medications
Are you currently taking:
Blood thinners
Corticosteroids (oral or injected)
Anti-inflammatory medication
None
Other medications or supplements we should know about:
Treatment Goal
What is your main goal with Shockwave Therapy?
Reduce pain
Improve joint movement
Return to activity or sport
Avoid injections or surgery
Improve daily function
Do you have any other health concerns we should know about?
Yes
No
If Yes, please describe:
Thank you so much for filling out the Shockwave & Adjunct Therapies New Patient Health Questionnaire. We look forward to helping you with your specific health concerns and overall well-being!
The Team at Santé Chiropractic and Wellness Centre
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