Belleville_Intial

Date of Initial Appointment

MonthDayYear
Who referred you to BIHC?
Reason(s) for Visit
Confidential Client Information
Name
Address
City
Province
Postal Code
(H) Phone #
(W) Phone #
(C) Phone #
Email
example@example.com
Age
Date of Birth

MonthDayYear
Pronouns:

She/Her/HersHe/Him/HisThey/Them/TheirsOther
Preferred Method of Contact (select one):

PhoneTextEmail
I agree to receive future email communications from B.I.H.C. containing news, updates and promotions. You may withdraw your consent at any time.

YESNO
Family Physician
Physician’s Phone Number
Emergency Contact Name
Emergency Contact relationship to you

SPOUSEFRIEND/FAMILY MEMBER
Emergency Contact Phone #
Medications

List any and all medications/supplements you are currently taking.
Medication Name #1
Dosage/Frequency #1
Condition it Treats #1
Medication Name #2
Dosage/Frequency #2
Condition it Treats #2
Medication Name #3
Dosage/Frequency #3
Condition it Treats #3
Medication Name #4
Dosage/Frequency #4
Condition it Treats #4
Medication Name #5
Dosage/Frequency #5
Condition it Treats #5
Medication Name #6
Dosage/Frequency #6
Condition it Treats #6
Medication Name #7
Dosage/Frequency #7
Condition it Treats #7
Client Condition
When did your symptoms appear
Change since onset of symptoms (Select one):

ImprovingNo ChangeRegressing
Rate severity of your pain on a scale from 0 (no pain) to 10 (severe pain)

0 - no pain12345678910 - severe pain
Type of Pain (Select all that apply):

SharpDullThrobbingNumbnessStiffnessAcheShootingBurningTinglingCramps
How often do you have this pain?
Does it interfere with your:

WorkSleepDaily RoutineRecreation
Activities that are painful to perform:

SittingStandingWalkingBendingLying DownTwistingCoughing/Sneezing
Please indicate if you have experienced any of the following recently:

Worsening headacheVision changesUnexplained dizzinessBowel/bladder dysfunctionUnexplained weight changesDifficulty sleepingNight painFever or night sweat
What is your overall health status?
Exercise:

NoneOccasionalFrequentDaily
Work Activity:

SittingStandingLight LabourHeavy Labour
Habits:

Smoking/VapeAlcohol/CaffeineHigh Stress
Indicate on the diagram where your symptoms are:

ABCDEFGHIJKLMNOPQRSTUVWXY
Accident Information
Is your condition due to an accident?

YESNO
If yes, what type of accident?

AutoWorkHome
Other:
Date of Accident

MonthDayYear
Date
Occupation
Employer
Health History
Present involvement in other health care (Select all that apply)

ChiropracticAcupuncturePhysiotherapyMassageNaturopathicChiropody/PodiatryOccupational TherapyPsychology/PsychiatryOther
Have you received any medical and/or drug treatment for this complaint?

YESNO
Please provide details:
Surgery #1
Date #1

MonthDayYear
Surgery #2
Date #2

MonthDayYear
Have you had any of the following tests for the condition(s) for which you are presently referred?

X-raysUltrasoundCT ScanMRIBone ScanEMGBlood TestOther
Please check all health conditions that apply:

AllergiesAnemiaAppendicitisArtificial JointsAsthmaBleeding DisordersBowel/Bladder ChangesBrain/Head InjuryBronchitisCancerCataractsChemical DependencyConcussionsCongestive Heart FailureConstipationDepression/AnxietyDiabetesDiarrheaDeep Vein ThrombosisEating DisorderEmphysemaEpilepsyFaintingFibromyalgiaFrequent ColdsGastrointestinal issuesGlaucomaGoutHeadaches/MigrainesHeart AttackHeart DiseaseHepatitisHerniaHigh Blood PressureHigh CholesterolHIV/AIDSIrritable Bowel SyndromeInternal Pins/PlatesKidney DiseaseLiver DiseaseLoss of SensationLow Blood PressureMenopauseMultiple SclerosisNausea or VomitingOsteoporosisOsteoarthritisPacemakerParkinson’s DiseasePneumoniaPregnantRheumatoid ArthritisRinging in earsShortness of BreathSkin ConditionsSinus ProblemsStroke/TIASurgeryThyroid DisorderTMJ DysfunctionTuberculosisUlcersVaricose VeinsVertigoVIsion ProblemsOther
Allergies
Type of Diabetes
# of weeks pregnant
Family Health History

Heart DiseaseStrokeArthritisCancerDiabetesOsteoporosis
Should be Empty:

Confidential Client Information

Medications

Client Condition

Accident Information

Health History