Belleville_Initial

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 #
Format: (000) 000-0000.
(W) Phone #
Format: (000) 000-0000.
(C) Phone #
Format: (000) 000-0000.
Email
example@example.com
Age
Date of Birth

MonthDayYear
Pronouns:

Other
Preferred Method of Contact (select one):
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.
Family Physician
Physician’s Phone Number
Format: (000) 000-0000.
Emergency Contact Name
Emergency Contact relationship to you
Emergency Contact Phone #
Format: (000) 000-0000.
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):
Rate severity of your pain on a scale from 0 (no pain) to 10 (severe pain)
Type of Pain (Select all that apply):
How often do you have this pain?
Does it interfere with your:
Activities that are painful to perform:
Please indicate if you have experienced any of the following recently:
What is your overall health status?
Exercise:
Work Activity:
Habits:
Indicate on the diagram where your symptoms are:
Accident Information
Is your condition due to an accident?
If yes, what type of accident?
Other:
Date of Accident

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

Other
Have you received any medical and/or drug treatment for this complaint?
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?

Other
Please check all health conditions that apply:

Other
Allergies
Type of Diabetes
# of weeks pregnant
Family Health History
Should be Empty:

Confidential Client Information

Medications

Client Condition

Accident Information

Health History