echelonbedford

VETERAN INTAKE FORM- PERSONAL CONTACT INFORMATION
Name*

First NameLast Name
Address
City
Province
Postal Code
Home Phone Number*
Mobile Phone Number
Email*
example@example.com
Date of Birth dd/mm/yyyy*

DayMonthYear
Date
Emergency Contact First and Last Names
Contact Number
Please enter a valid phone number.
Relationship
I consent for Echelon Wellness to send me texts and emails or to call me to regarding important information (appointment reminders)

YesNo
Can we leave a voicemail on the phone numbers you have provided?

YesNo
Would you like to receive information about Programs and announcements?

YesNo
Family Doctor
Phone Number
Previous Illnesses/Operations (Include dates):
Current Medications & Supplements:

0/80
Allergies & Reactions
AFFILIATION WITH CANADIAN FORCES/RCMP
Medically Released from the Canadian Forces?

YesNo
Released from the Canadian Armed Forces?

YesNo
Presently Serving Member

YesNo
RCMP

ActiveVeteranN/A
Regimental Number
HEALTH INSURANCE
Primary Benefits Provider: Medavie BlueCross
K#
Do you have a Pensioned Condition(s):

YesNo
Pensioned Conditions:

0/100
Are you looking for a Pension Assessment?

YesNo
Condition/Area of body for Assessment:

0/100
How did you hear about Echelon Wellness?
HEALTH HISTORY

Please check all that apply:
General Symptoms

Allergies/SensitivitiesFainting / DizzinessHeadaches / MigrainesNervousnessNumbness/TinglingParalysisPoor MemoryTrouble Sleeping/Fatigue
Skin Conditions

AcneExcessive DrynessEczemaHair loss / ThinningPsoriasisRashes / Skin SensitivityThin/Brittle Nails
Infections

Athlete’s Foot/WartsHepatitisHIV/AIDSTuberculosisHerpesWartsOther
Respiratory

AsthmaBronchitisChronic CoughCOPDDifficulty BreathingEmphysemaPostnasal DripShortness of Breath
EENT

Dental ProblemsVisual ProblemsHearing Loss / AidEaraches / Ringing EarsSore ThroatStuffy / Runny NoseJaw Pain: Clicking/LockingRecurrent Sore ThroatRinging in Ears/TinnitusSwollen Glands
Musculoskeletal

Arthritis / Joint PainBursitisCancerFibromyalgiaMultiple SclerosisOsteoporosisArtificial Implants, Pins or Plates:
If any impacts/pins/plates, please describe
Mental Health

AnxietyBi-Polar DisorderDepressionEating DisorderPsychosisPTSDSchizophreniaSubstance Misuse/AbuseOther
Cardiovascular

Chest PainCold Hands / FeetCongestive Heart FailureEdema / SwellingHeart Attack / DiseaseHigh/Low Blood PressureHigh CholesterolPacemakerPoor CirculationStroke / AneurysmVaricose Veins / Phlebitis
Gastrointestinal/Endocrine

Abdominal CrampsColitis / Crohn’s / IBSConstipation / DiarrheaDiabetesExcessive ThirstGERD / Acid RefluxGoutGall Bladder ProblemsLiver ProblemsGas / BloatingKidney StonesNausea / VomitingPoor / Excessive AppetiteUlcers
Male / Female Health

Breast Pain / LumpsBreast ImplantsEndometriosis / FibroidsErectile DysfunctionIncontinenceInfertilityMenstrual CrampingMenstrual IrregularityPeri- / MenopausalPCOSPregnantProstateVaginal Pain / Infections
If pregnant, what is your due date?

DayMonthYear
Date
Lifestyle: Do you exercise regularly?
Do you drink water?
Do you maintain a healthy diet?
Do you have poor/inadequate sleep?
Do you smoke?
If yes, how many per week?
Do you drink alcohol?
If yes, how many drinks per week?
Please use this daigram to indicate areas of involvement/chirf complaint (if applicable)

^^^ Numbness

000 Pins and Needles

XXXX Burning

**Aching/Dull

/// Stabbing/Sharp

EEE Electrical

Example: B^^^000, T***
Please list areas here

Select the products or services you have previously tried or are receiving currently. Also please indicate whether you experienced success or are interested in learning more about these treatments.

	PAST	CURRENT	SUCCESS YES	SUCCESS NO	INTERESTED
Topical Pain Creams
Custom Orthotics
Compression Stocking
TENS Unit
Orthopedic Bracing (Back, Knee, Ankle, Shoulder, Elbow, Wrist, Hand)
Medical Cannabis

PHYSICAL HEALTH SERVICES

	PAST	CURRENT	SUCCESS YES	SUCCESS NO	INTERESTED
Chiropractic
Physiotherapy
Massage Therapy
Acupuncture/Dry Needling
Erectile Dysfunction (Shockwave)
Osteopathy
Chronic Pain Shockwave

NON-PHYSICAL HEALTH SERVICES

	PAST	CURRENT	SUCCESS YES	SUCCESS NO	INTERESTED
Psychologist / Psychiatrist
Social Work
Couple / Marital Counselling
Group Therapy
Cannabis Therapy

VETERAN HISTORY
Do you have your pensioned conditions paperwork or summary of assessment?

YesNo
Are you receiving any of the following: Long term disability (SISIP)?

YesNo
Earnings Loss Benefit (VAC)

YesNo
If yes, have you received any money for schooling?

YesNo
CONSENT TO DISCLOSE STATEMENT
I authorize Echelon Wellness to disclose my personal health information to health care custodians within the facility as needed to deliver my continued care.
Initial*
I understand that Echelon Wellness does not replace my family physician.
Initial*
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

AFFILIATION WITH CANADIAN FORCES/RCMP

HEALTH INSURANCE

HEALTH HISTORY

VETERAN HISTORY

CONSENT TO DISCLOSE STATEMENT