zenith_Chiropractic

PHYSIOTHERAPY CHIROPRACTIC MASSAGE I LASER THERAPY I CUSTOM ORTHOTICS I SHOCKWAVE THERAPY
CHIROPRACTIC INTAKE AND HEALTH INFORMATION FORM
Name

First NameLast Name
Gender

MF
Address
Date of Birth

MonthDayYear
Date
City
Province
Postal Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Email Address
example@example.com
Consent to receive emails
Emergency Contact
Phone#
PART B
Referring Physician
Alberta Health Care Number
Family Physician
Medical Clinic
Do you have extended Health Care?

YesNo
If yes, Please Specify:
PART C
Is this injury from a Motor Vehicle Accident? (If YES, please complete additional MVA Questionnaire)

YesNo
Is this injury a Worker’s Compensation claim? (If YES, please complete additional WCB Questionnaire)

YesNo
PART D - Health Report
What is the reason for which seeking care today
List any other doctors seen for this
List any diagnosis and type of treatment
Have you had similar accidents or injuries before?

YesNo
If yes explain
List the names of any relatives that have or have had a similar problem
Have you or any relative received chiropractic treatment previously?

YesNo
If yes explain
Have you been treated for any health condition by a physician in the last year?

YesNo
If yes explain
Are you currently taking medication?

YesNo
list medications
Have you taken medication in the past?

YesNo
list medications
List conditions you are taking medications for
List the approximate dates of any surgery or treated conditions
Family History: Health conditions, age of death and cause of death.
Father
Mother
Brother/s & Sister/s
Do you smoke?

YesNo
Drink Alcohol?

YesNo
If yes,

DailyWeeklySocial Occasions
Caffeinated drinks per day
Do you take Vitamins/Supplements

YesNo
If yes, type and how often
Please select the degree of pain

0 - none12345678910 - severe pain
Using the symbols below, please indicate using the coresponding letters on the diagram where you feel pain.

Dull Ache ooo Numbness = = Sharp/Stabbing /// Pins, Needles +++ Burning XXX

Example: D+++
What activities aggravate your condition/pain?
What activities lessen your condition/pain?
Is this condition worse during certain times of the day?

YesNo
Is this condition interfering with:

Work?Sleep?Routine?Other
Is this condition progressively getting worse?
GENERAL SYMPTOMS

ConvulsionsDizzinessFaintingHeadacheNervousnessNumbnessType option 7
CARDIO-VASCULAR

High Blood PressureHeart AttackPain over heartPoor CirculationHeart TroubleRapid HeartSlow HeartStrokesSwelling AnklesVaricose Veins
MUSCLE & JOINTS

Low back problemsPain between shouldersNeck ProblemsArm ProblemsLeg ProblemsSwollen ProblemsPainful JointsStiff JointsSore MusclesWeak MusclesWalking problemsSprains/StrainsBroken bones
EAR/NOSE/THROAT

Ear acheEar NoisesEnlarged ThyroidFrequent ColdsHay FeverNasal BlockagePain behind eyesPoor VisionSinusitisSore throat
GASTRO- INTESTINAL

Belching/ GasColon ProblemsConstipationDiarrheaExcessive HungerExcessive ThirstGallbladder troubleHemorrhoidsLiver/ GallbladderNauseaAbdominal PainUlcerPoor AppetitePoor DigestionVomitingBlack stoolBloody StoolTonsillitis
RESPIRATORY

AsthmaChronic CoughDifficulty BreathingSpitting BloodSpitting Phlegm
GENITO-URINARY

Blood in UrineFrequent urinationKidney InfectionPainful UrinationProstate ProblemsLoss of Bladder Control
SKIN ALLERGIES

BoilsBruising EasilyDrynessEczema/Rash/DermatitisHivesItchingSensitive SkinAllergy
FOR WOMEN ONLY

Birth ControlHormone ReplacementCramps/ back achesExcessive FlowHot flashesIrregular CycleMiscarriagePainful PeriodsVaginal DischargeBreast Pain
List allergy
List birth control
Pregnant at this Time

YesNo
I hereby certify that the statements and answers given on this form are accurate to the best of knowledge and understand it is my responsibility to inform this office of any charges in my health.

I agree to allow this office to examine further evaluation.
Patient Signature

Clear
Date

MonthDayYear
Date
PART E

Chiropractic Fees and Payment Policy

The purpose of this section is to clarify your financial responsibilities in relation to your treatment.

✔ The patient is responsible for the full payment of services at the time services are rendered.

✔ Depending on your policy, your extended health benefit plan(s) may cover some or all the treatment cost. We offer direct billing to most insurance plans. However, some plans may not allow direct billing. Direct billing is a courtesy payment option that is offered by some benefit providers. We will try to direct bill your provider where this is applicable. However, we do not have control over this. So please check with your benefits administrator for more information.

✔ In all cases, patients are responsible for the full payment at the time services are rendered. We accept Cash, Debit, Visa, MasterCard.

✔ If you are attending treatment because of a motor vehicle accident, you must provide our office with all the relevant information (claim number, adjustor name, etc.) for us to process your claim. For Patients receiving treatments out of Protocol (Section B), If you have extended health benefit (EHB) coverage for the treatment you are receiving (Physio, chiro, massage), your Extended Health Benefit provider is the primary payer for your treatment. If there’s any portion of your payment not covered by your EHB, or if you have exhausted your EHB coverage for the year, then your Motor vehicle insurance coverage may cover the remaining portion (Subject to approval by your motor vehicle insurance adjuster .. However, your motor vehicle insurance may not approve direct billing for your treatments, in that situation you are primarily responsible for the payment of the full cost of your treatment. All payments are due and must be paid on the day of the treatment.
I have read, understood and agreed to the fees and payment policies and agree with my financial obligations as explained above.
Patient Signature

Clear
Date

MonthDayYear
Date
Part G

Clinic Policy

Privacy Policy: Zenith Physiotherapy and Wellness Clinic is committed to controlling and protecting the collection, use and disclosure of the personal information provided by its patients. Our policy is guided by the Canadian Standards Association Model Code, and synthesizes relevant material from the Protection of Personal Information Protection and Electronic Documents Act (PIPEDA), Alberta Personal Information Protection Act (PIPA) and Health Information Act (HIA A complete copy of Zenith Physiotherapy and Wellness Clinic Private Policy is available on our website at: www.zenithphysio.com

Appointments

✔ Please be on time for your appointment.

✔ We highly advise you to book your appointments at the beginning of each week.

✔ If you miss several appointments without reason, we may have to notify your insurance company, WCB and you may be discharged for the missed appointment if you do not notify us prior to your appointment time.

✔ Patients are liable for a fee of $25.00 for each canceled or missed appointment if you do not notify us at least 24 hours before your appointment time.

Clothing and attire:

✔ Please wear/bring along clothing appropriate for treatment. If you are unsure, ask your therapist for guidance at your initial visit

✔ No perfumes, strong body odors, or excessive scents

Safety:

✔ Children must be under adult supervisor and are not to play with any equipment

✔ Please notify your treating therapist of any change in your condition or anything you are unsure about

✔ Please call for assistance immediately if you are in any discomfort during your treatment

✔ If you have inhalers or nitro spray or other emergency medication, please have it with you at all times while in the clinic

Food and Drinks:

✔ No food or drinks are allowed inside the clinic at any time.

Telephone calls

✔ We kindly ask that you turn off or put your cell phones in silent mode to ensure a private and comfortable treatment environment.

Lost or Stolen Items:

✔ We are not responsible for any items lost or stolen while attending our facility

Reports/Work Notes:

✔ A fee may be applicable for reports and / or work notes. Please see the front desk for further detailsWork Injuries:
Patient Signature

Clear
Date

MonthDayYear
Date
PART H
Lastly, Who can we thank for referring you to us?

My Physician referred me to Zenith PhysioPrevious Zenith Physio PatientLaw FirmInsurance CompanyAdvertisement/Signage/Newspaper/NewsletterWebsite/Facebook/Google SearchOther Locake Services/BusinessOther
Should be Empty:

CHIROPRACTIC INTAKE AND HEALTH INFORMATION FORM