midhurstphysio_Chiro

MIDHURST WELLNESS CENTRE: CONFIDENTIAL MEDICAL INFORMATION
DATE

MonthDayYear
Date
NAME
Address

ADDRESS

Street Address Line 2

CITYState / Province

Postal Code
DATE OF BIRTH

YearMonthDay
Date
PRIMARY PHONE no.
Format: (000) 000-0000.
Check:
EMAIL ADDRESS or ALTERNATE PHONE no.
INJURY/AREA TO BE TREATED:
Motor Vehicle Accident Claim

MonthDayYear
date of accident
WSIB Claim

MonthDayYear
date of injury
EXTENDED HEALTH CARE COVERAGE THROUGH MY PLAN:
EXTENDED HEALTH CARE COVERAGE THROUGH MY SPOUSE OR OTHER:
I am aware that if I qualify for online billing, I am still responsible to keep track of treatment costs and how much coverage is available from my plan. I am responsible for any treatment costs not covered by my plan.
Initial
I WAS REFERRED TO Midhurst Wellness Centre BY:

Other
FAMILY PHYSICIAN
CITY
REFERRING PHYSICIAN
CITY
I, undersigned, herewith consent to treatment for above-mentioned condition(s), and to the communication between the treating professionals at this clinic and/or Physicians or other Health Care Professionals.

I am aware that there is a 24 hour cancellation policy and may be charged for a missed appointment.
SIGNATURE

Clear
Health Status Survey
Patient Name
File #
Date

MonthDayYear
Date
Please X the box for any conditions or symptoms presently causing you problems.
Please check (✓) the box for those conditions or symptoms that you have had in the past.
General Symptoms
Neurologic
Muscles and Joints
Eyes/Ears/Nose/Throat
Respiratory
Cardiovascular
Genitourinary
GU for Women
Currently on birth control pills/patch?
Previously on birth control pills/patch?
# of pregnancies
# of children
Are you, or could you be pregnant? (if female)
Skin
Gastrointestinal
Have you ever had any fractures?
If yes - where?
Have you ever been in a car accident?
If yes - when?
Have you ever been hospitalized?
Why/When?
Are you currently a smoker?
How much?
Did you smoke previously?
How much?

Have you ever been diagnosed:

Rows	yes	no
With cancer?
With HIV/AIDS?
With Hep A/B/C?

Medications (list):
Clinician Comments:
Should be Empty:

MIDHURST WELLNESS CENTRE: CONFIDENTIAL MEDICAL INFORMATION

Health Status Survey