New Patient Intake Forms

755 Griffith Court, Unit 1 Burlington ON L7L5R9 905 632 0462 (P) 905 632 6277 (F)
PATIENT INFORMATION
Please Print
Name:_________________________________ Address:_________________________________________
City:__________________________________Postal Code:_______________________________________
Phone #: (Home) ____________________(Alternate)____________________Date of Birth: ____/____/____
year/month/day
Occupation: ________________________ Whom may we thank for referring you? _____________________
Email address:__________________________ Emergency Contact:________________________________
Medical Doctor: ______________________ City: ______________________ Phone #:__________________
Chiropractor/Physio/other: ______________________ City:_________________ Phone #:_______________
OFFICE POLICIES & INFORMATION
Thank you for choosing our team at HealthQuarters Inc. Your appointment has been scheduled especially for
you and a specific time has been allotted. If you need to cancel or reschedule your appointment we require 24
hours of notice; late cancellation or a missed appointment will result in a charge of the full fee for the
scheduled service.
To provide you with the most effective, multi-disciplinary team care at HealthQuarters Inc., your case may be
discussed amongst our treatment providers. A health care provider other than your initial visit practitioner,
may from time to time read or have access to your patient file. Any personal and/or health information is
handled with strict confidentiality, abiding by the rules and regulations of the provincial privacy acts
(PHIPPA & PIPEDA).
Payment for products and services are due at the time of your appointment. We would be happy to provide
you with the necessary documents/invoices for you to submit to your insurance company for reimbursement.
As you are ultimately responsible for the cost of the services provided at HealthQuarters Inc., you may wish
to inquire about the type of coverage you have through your insurance carrier. The majority of our services
are covered by extended health benefit plans. Please ask for additional information in regards to our current
services provided, should you wish to may this inquiry.
If you have any questions or concerns regarding your treatment, or would prefer to be treated in a private
therapy room, please speak to any of the team members at HealthQuarters Inc.
I have read and understand the office policies & information section. By signing below, I agree to the above,
Signature _________________________
Date___________________
Please check off all applicable boxes below (past and current):
Cardiovascular
Musculo-skeletal
Skin
Nervous System
o High blood pressure
o Low blood pressure
o Chronic congestive heart
failure
o Heart disease
o Myocardial infarction
o Phlebitis
o Cardio-vascular accident
o Stroke
o Pacemaker
o Varicose veins
o Blood clots
o Osteoarthritis
o Lymphedema
o Other
o Bone or joint disease
o Tendonitis
o Bursitis
o Fractures
o Osteoarthritis
o Rheumatoid arthritis
o Sprains/strains
o Swelling
o Stiffness
o Spasms/cramps
o Pain (check area)
__Jaw __Neck __Shoulder
__Elbow __Wrist __Hip
__Knee __Ankle __Back
o Allergies (anaphylactic)
o Rashes
o Athletes foot
o Warts
o Cold sores
o Eczema/psoriasis
o Other (contagious)
o Herpes/shingles
o Numbness/tingling
Chronic pain
o Fatigue
o Sleep disorder
o Loss of sensation
o Other
Respiratory
Other
Digestive
Infectious Diseases
o Hepatitis
o Tuberculosis
o HIV
o Other
o Constipation
o Gas/bloating
o Nausea/vomiting
o Irritable bowel syndrome
o Liver/gall bladder
○Kidney/bladder
o Chronic cough
o Bronchitis
o Shortness of breath
o Asthma
o Emphysema
o Smoking
o Other
Reproductive
o Drug/alcohol addiction
o Nicotine/caffeine addiction
o Diabetes
o Vision/hearing loss
o Headaches/migraines
o Cancer
o Epilepsy
o Allergies (please list)
○other conditions not listed
_____________________
o Pregnancy (trimester __)
o PMS
o Other
INDICATE AREAS OF PAIN OR DISCOMFORT
○Place an “X” on areas of
extreme pain
○Circle areas of discomfort
○use comment section to
list any concerns or details
of injuries, surgeries….
*Provide any details regarding injury
or condition.
HEALTH HISTORY QUESTIONNAIRE
Have you had previous care for this condition? ______ When? (Include last visit date) __________________
Where? (Include Dr’s name) ________________________________________________________________
Why? __________________________________________________________________________________
Were Xrays or other imaging/tests performed? (Include date) ______________________________________
Main reason for consulting this office: _________________________________________________________
Other health concerns: _____________________________________________________________________
How long have you had this condition? ____________ Have you had this or similar conditions in the past? ______
What activities aggravate your condition? __________________________________________________________
Is this condition getting progressively worse? (Circle)
Yes No
Improving
Staying the same
Is this Condition interfering with your (Circle)
Work Sleep Daily Routine Other _____________________
How long has it been since you really felt good? _____________________________________________________
Have you been diagnosed with a medical condition? __________________________________________________
Have you ever been hospitalized? (Circle) Yes No
If yes, for what? ___________________ When? _______
Have you ever had surgery? (Circle) Yes No
If yes, for what? ______________________ When? __________
Prescribed Medication(s) you take now: (Circle)
Allergy/Inhaler
Anti-inflammatory Anti-depressant
Blood Pressure
Heart Pill
Cholesterol Pill
Hormone Replacement Pill
Insulin
Thyroid Pill Birth Control Pill
Other _____________________________
Have you experienced any adverse effects? (eg. Indigestion, Hives, Constipation, etc) _________________________
Do you have a lot of stress in your life? ________________
Do you get enough regular sleep? ____________
Approximate age of your mattress ___________ Is it comfortable? _________ Are your pillows comfortable? _______
Do you wear (Circle) Custom Prescribed Orthotics
Heel/Sole Lifts
OTC Arch Supports
What type of regular exercise do you perform? _______________________________________
How much water do you drink daily? ______________________ Do you eat well balanced meals regularly? ________
How much coffee do you drink daily? _____________ Do you smoke? ________________
Are you taking any vitamins/supplements? ___________ Please List: ________________________________________
Have you ever been in an auto accident? (Circle) Past Year
Past 5 years Over 5 years Never
Describe: ___________________________________________________________________
Have you had any other personal injuries or accidents? (Circle) Past Year Past 5 Years Over 5 Years Never
Describe: ___________________________________________________________________
What is your health goal? (Please circle one)
 RELIEF CARE: Only relieves the pain and symptoms
 CORRECTIVE CARE: Addresses the cause of the problem as well as reduces the pain and symptoms.
 WELLNESS CARE: Correct the cause of the problem and work to improve function of health so as to prevent
further injury or conditions.
FAMILY HEALTH HISTORY
Please list which of your immediate family members (father, mother, sibling, children) have been diagnosed with the
following:
__________Cancer __________Arthritis __________Heart Disease __________Stroke
__________Diabetes __________High Blood Pressure
__________Low Blood Pressure
__________Other
Please list any additional health history information:
____________________________________________________________________________________________