Confidential Patient Information
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2Glenmore Chiropractic
Confidential Patient Information
□ Yes
□ No
Is this an ICBC/Worksafe injury?
If YES please note that we do NOT deal directly with ICBC or Worksafe.for billing.
Name: __________________________________ Address: ___________________________________________________
City: _______________ Province: ______ Postal Code: __________
Primary Phone #: _________________________
E-mail: __________________________________________________________
***WE DO NOT DO PHONE REMINDERS. Your email address will ONLY be used for sending appointment reminders or to
advise of changes at the clinic or with your appointment; insurance claim status or follow up for treatments. We will NOT share
( )
your email or any personal information with anyone. If you do not wish to receive email reminders please check this box
If at
any time you wish to be removed from our email list please notify the office by phone or email and we will remove you
immediately.
Employer: ________________________________________ Type of work: _____________________________________
□ Male
□ Female
□ M
□ S
□ D
□ W
Date of birth: _______________ Age: ______
Marital Status:
Name of Emergency Contact: _________________________________
Phone: ____________________________
Family Physician: ________________________________
BC MSP Care Card # ______________________________
How did you hear about our office
? _____________________________________________________________________
Extended Benefits Information (Name of Company/Group & ID #): _____________________________________________________
1. What is your main complaint(s)? ______________________________________________________________________________
□ Work injury
□ Sports injury
□ Auto accident
□ Home accident
2. How did this condition begin?
□ Chronic (long-term) discomfort □ Other (please describe) _______________________________________________________
3. How long have you suffered with this condition:
_____ Day (s)
_____Week (s)
_____ Month (s)
_____ Year (s)
□ Yes
□ No
4. Have you experienced previous episodes of this condition?
□ Gotten worse
□ Gotten better
□ Stayed constant
□ Comes & goes
5. Has this condition:
□ Sharp
□ Dull
□ Achy
□ Burning
□ Numbness
□ Pins & needles
6. Character of the condition:
□ Mild
□ Moderate
□ Severe
7. Intensity of the condition:
□ Sitting
□ Standing
□ Bending
□ Lifting
□ Walking
□ Lying
8. Aggravating factors:
□ Other (please describe) __________________________________________________________________________________
□ Bed rest
□ Ice
□ Heat
□ Medication
□ Massage therapy
9. Relieving factors:
□ Other (please describe) __________________________________________________________________________________
10. Does this condition interfere with: □ Work
□ Family
□ Sports/hobbies
□ Other: _______________________________
□ Acupuncture
□ Medication
□ Physiotherapy
□ Massage Therapy
11. What other types of treatment have you tried:
□ Other (please describe) ____________________________________________________________________________________
Turn Over
FILE # __________________
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