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.
Check:

CellHomeWork
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:

YESNO
EXTENDED HEALTH CARE COVERAGE THROUGH MY SPOUSE OR OTHER:

YESNO
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:

DOCTORFRIEND/FAMILYI AM A REPEAT PATIENTWALK-INYELLOWPAGES.CAYELLOWPAGES PHONEBOOKGOOGLEADVERTISEMENTOther
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

Loss of consciousnessBlackoutsHeadacheFeverExcess sweatingNight sweatsLoss of weightNight painGeneralized painNervousnessConvulsionsLoss of sleep
Neurologic

DizzinessFaintingProblem speakingProblem swallowingBlurred visionDouble visionNauseaClumsinessNumbness of tingling
Muscles and Joints

Sore/stiff neckMid back acheLow back achePainful tailboneShoulder painArm/forearm painElbow painWrist/hand painHip painKnee painAnkle/foot troubleArthritisLoss of strength
Eyes/Ears/Nose/Throat

Failing visionEye painFailing hearingEaracheRing/buzz in earsFrequent coldsSinus infectionEnlarged thyroidEnlarged glands
Respiratory

AsthmaChronic coughSpitting up phlegmSpitting up bloodDifficulty breathing
Cardiovascular

Bleeding disorderHigh blood pressureChest painStrokeHardening of arteriesVaricose veinsSwelling of anklesPoor circulationHeart/blood diseaseAngina
Genitourinary

Trouble urinatingBlood in urineKidney infectionBedwettingProstate trouble
GU for Women

Painful menstruationExcessive flowHot flashesIrregular/absent cycleCramping/backacheVaginal dischargeSwollen breastsLump in breasts
Currently on birth control pills/patch?

yesno
Previously on birth control pills/patch?

yesno
# of pregnancies
# of children
Are you, or could you be pregnant? (if female)

yesno
Skin

Rashes/itchingBruise easyDrynessBoilsHives (allergies)
Gastrointestinal

Poor appetiteIndigestionExcess hungerBelching or gasVomitingPain over stomachConstipationDiarrheaHemorrhoids (piles)JaundiceGall bladder troubleIntestinal wormsUlcerDiabetes
Have you ever had any fractures?

yesno
If yes - where?
Have you ever been in a car accident?

yesno
If yes - when?
Have you ever been hospitalized?

yesno
Why/When?
Are you currently a smoker?

yesno
How much?
Did you smoke previously?

yesno
How much?

Have you ever been diagnosed:

	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