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
She/Her/HersHe/Him/HisThey/Them/TheirsOther
PhoneTextEmail
YESNO
Family Physician
Physician’s Phone Number
Format: (000) 000-0000.
Emergency Contact Name
SPOUSEFRIEND/FAMILY MEMBER
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
ImprovingNo ChangeRegressing
0 - no pain12345678910 - severe pain
SharpDullThrobbingNumbnessStiffnessAcheShootingBurningTinglingCramps
How often do you have this pain?
WorkSleepDaily RoutineRecreation
SittingStandingWalkingBendingLying DownTwistingCoughing/Sneezing
Worsening headacheVision changesUnexplained dizzinessBowel/bladder dysfunctionUnexplained weight changesDifficulty sleepingNight painFever or night sweat
What is your overall health status?
NoneOccasionalFrequentDaily
SittingStandingLight LabourHeavy Labour
Smoking/VapeAlcohol/CaffeineHigh Stress
ABCDEFGHIJKLMNOPQRSTUVWXY
Accident Information
YESNO
AutoWorkHome
Other:
Date of Accident

MonthDayYear
Date
Occupation
Employer
Health History
ChiropracticAcupuncturePhysiotherapyMassageNaturopathicChiropody/PodiatryOccupational TherapyPsychology/PsychiatryOther
YESNO
Please provide details:
Surgery #1
Date #1

MonthDayYear
Surgery #2
Date #2

MonthDayYear
X-raysUltrasoundCT ScanMRIBone ScanEMGBlood TestOther
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
Heart DiseaseStrokeArthritisCancerDiabetesOsteoporosis
Should be Empty:

Confidential Client Information

Medications

Client Condition

Accident Information

Health History