echelonnf_intake

VETERAN INTAKE FORM- PERSONAL CONTACT INFORMATION
Name

First NameLast Name
Address
City
Province
Postal Code
Home Phone Number
Format: (000) 000-0000.
Mobile Phone Number
Format: (000) 000-0000.
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.Format: (000) 000-0000.
Relationship
I consent for Echelon Wellness to send me texts and emails or to call me to regarding important information (appointment reminders)
Can we leave a voicemail on the phone numbers you have provided?
Would you like to receive information about Programs and announcements?
Family Doctor
Phone Number
Format: (000) 000-0000.
Previous Illnesses/Operations (Include dates):
Current Medications & Supplements:

0/100
Allergies & Reactions
AFFILIATION WITH CANADIAN FORCES/RCMP
Medically Released from the Canadian Forces?
Released from the Canadian Armed Forces?
Presently Serving Member
RCMP
Regimental Number
HEALTH INSURANCE
Primary Benefits Provider: Medavie BlueCross
K#
Do you have a Pensioned Condition(s):
Pensioned Conditions:

0/120
Are you looking for a Pension Assessment?
Condition/Area of body for Assessment:

0/120
How did you hear about Echelon Wellness?
HEALTH HISTORY

Please check all that apply:
General Symptoms
Skin Conditions
Infections

Other
Respiratory
EENT
Musculoskeletal
If any impacts/pins/plates, please describe
Mental Health

Other
Cardiovascular
Gastrointestinal/Endocrine
Male / Female Health
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.

Rows	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

Rows	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

Rows	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?
Are you receiving any of the following: Long term disability (SISIP)?
Earnings Loss Benefit (VAC)
If yes, have you received any money for schooling?
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