To The New Patients
Outline of Procedure for New Patients

If you have been injured in an accident, or this is a WORKERS COMPENSATION injury please advise the front desk
 when you arrive at your first appointment.

STEP ONE:
All new patients are requested to completely fill out a personal health/history questionnaire.
STEP TWO:
You will have a consultation with a doctor to discuss your health problems.
STEP THREE:
Diagnostic chirpractic, orthopedic, and neurological examination procedures may be performed to determine if chiropractic care is appropriate for your condition.
STEP FOUR:
The doctor will advise you as to the need of any additional procedures such as laboratory and or x-ray tests, if necessary.
STEP FIVE:
If your case requires immediate attention, emergency care will be administered.
STEP SIX:
You will be advised as to a time you can return for your "Report of Findings" when your doctor will review your examination resutls and whether or not your case has been accepted.
STEP SEVEN:
After you return and receive your "Report of Findings" your recommended treatment program will be explained
to you. You will also be advised concerning financial arrangements, options and insurance coverage as it
applies to you.

PERSONAL HISTORY

Date : 09 Dec 2003		Birth Date : _______ / _____ / ____
Name : _________________________________ Address : _______________________________ City : __________________________________ Prov : ___Postal Code : _________		Home Phone : ( ___ ) _________________ Bus. Phone : ( ___ ) __________________ Fax Number : ( ___ ) _________________ E-mail : ____________________________
Sex : M F		Height ______ Weight _______
# of Children : ___ Ages : _________________		Check One: Married Single Widowed Divorced   Separated
Business/Employer : _______________________________________ Type of Work : _________________________

Referred to this office by: ________________________________________________________

INSURANCE INFORMATION

O.H.I.P. Health Card # : ____________________ Version Code : ___ Expiry : _____ / ___ / _____

SUPPLEMENTARY HEALTHCARE

Company : ____________________________________ Policy No. _____________________________

LIST COVERAGE
Chiropractic __________________________________________________________________________

Physiotherapy ________________________________________________________________________

Active Rehab _________________________________________________________________________

Orthotics _____________________________________________________________________________

Massage Therapy _____________________________________________________________________

Chiropody ___________________________________________________________________________

CURRENT HEALTH CONDITION
Current Complaint(s):
_____________________________________________________________________________________

_____________________________________________________________________________________

Other Doctors seen for this condition: Y N   Who? _____________________________

Type of Treatment : ______________________ Results : ____________________________________

When did the condition begin? ____________________
Is condition : Job-related Auto-related Home-inury Fall Other ____________

Date of Accident : _________/_____/____ Time of Accident : _______________________





What of the following aggravates your condition?
Sitting Standing Bending Lifting Walking Lying Down Cold
Dampness Other ___________________________________

What relieves your condition?
Bed Rest Ice Heat Massage Medication Other

Is it getting :
Worse Constant Comes/Goes Better

Character of pain:
Sharp Dull Ache Pins & Needles Numb Burning Constant
Intermittent

Duration of Symptom:
Intermitten (25% of the time) Occasional (25-50%) Frequent (50-75%)
Constant (75-100%) Other (i.e. with movement or position)

Drugs you now take :
Nerve Pills Painkillers/Muscle Relaxers Blood Pressure Medicine Insullin
Other __________________________________________________

Do you suffer from any other condition other than that for which you are consulting us?

_________________________________________________________________________________

_________________________________________________________________________________

On a scale of 1 to 10, 10 being the highest, rate your commitment to correcting this problem.
1 2 3 4 5 6 7 8 9 10

Have you had x-rays taken in the last 6 months? Y N

When did this condition begin? ____________________________

Are their others in your family with this same condition? Y N








 

Below are a list of diseases which may seem unrelated to the purpose of your appointment.
However, these questions must be answered carefully as thse problems can effect your overall
 course of chiropractic care.

CHECK ANY OF THE FOLLOWING DISEASES YOU HAVE HAD:

Pneumonia Rheumatic Fever Polio Tuberculosis Whooping Cough Anemia Measles

Mumps Small Pox Chicken Pox Diabetes Cancer Heart Disease Thyroid

Influenza Pleurisy Epilepsy Mental Disorder Lumbago Eczma

CHECK ANY OF THE FOLLOWING YOU HAVE HAD IN THE PAST 6 MONTHS:

MUSCULO-SKELETAL CODE Low Back Pain Leg Pain Pain Between Shoulders Neck Pain Arm Pain Joint Pain/Stiffness Walking Problems Difficult Chewing Clicking Jaw		NERVOUS SYSTEM CODE Nervous Numbness Paralysis Dizziness Forgetfullness Confusion/Depression Fainting Convulsions Cold/Tingling Extremeties Stress Subluxations		GENERAL CODE Fatigue Allergies Loss of Sleep Fever Headaches Decreased Wellness
C-V-R CODE Chest Pain Short Breath Blood Pressure Problems Irregular Heartbeat Heart Problems Lung Problems Congestion Varicose Veins Ankle Swelling Stroke		FEMALES ONLY: When was your last period? __________/_______/______ Are you pregnant? Y N Not Sure Menstrual Irregularity Menstrual Cramping Vaginal Pain/Infections Breast/Pain Lumps

The purpose of Alliance Healthcare Professionals is to support each individual
in achieving their optimum health & wellness and to educate them so that they
may understand health and chiropractic and in turn educate others.
"A candle loses nothing by lighting another candle"

Why Chiropractic? People go to Chiropractors for a variety of reasons. Some go for symptomatic relieft of
pain or discomfort (Relief Care). Others are interested in having the cause of the problem as well as the
ymptoms corrected and relieved (Corrective Care). Still others want whatever is malfunctioning in their bodies
brought to the highest state of health possible with Chiropractic care (Preventive/Wellness Care). These are
the three phases of care. Your doctor will weigh your needs and desires when recommending your schedule
 of care. However, his prepared recommendation is an incorporation of all three phases.

Please check the type of care desired so that we may guided by your wishes whenever possible.
Relief Care Corrective Care Preventative/Wellness Care
Check here if you want the Doctor to select the type of care appropriate for your condition.

INFORMED CONSENT TO CHIROPRACTIC ADJUSTMENTS AND CARE

I hereby request and consent to the performance of Chiropractic adjustments and other Chiropractic
procedures, including various modes of physical therapy and, if necessary, diagnostic x-rays, on me by
the doctor of Chiropractic listed below.

I have had an opportunity to discuss with the doctor of Chiropractic named below and/or with other office
or clinic personnel, the nature and purpose of Chiropractic adjustments and other procedures. I understand
that results are not guarenteed.

I further understand and I am informed that, as in all health care, in the practise of Chiropractic there are
some very slight risks to treatment, including, but not limited to, muscle strains and sprains, disc injuries,
and strokes. I do not expect the doctor to be able to anticipate and explain all risks and complications and
 I wish to rely on the doctor to exercise judgement during the course of the procedure which the doctor
feels at the time, based upon the facts then known, is in my best interests.

I have read the above consent. I have also had an opportunity to ask questions about its consent, and by
signing below I agree to the above named procedures. I intend this consent form to cover the entire course
 of treatment for my present condition and for any future condition(s) for which I seek treatment.

TO BE COMPLETED BY PATIENT

Enter Patients Name : _______________________________________________

Signature of Patient : ________________________________________________

Date : ____________/_______/_____

 232 South Service Road ~ Oakville, Ontario  L6J 2X5 Canada
tel: 905-845-2291 fax: 905-845-5606 ~ [email protected]