New Patient Intake Form
Date: Click here to enter a date.
Name:
Address:
City/Province/Postal code:
Phone number: (h) (c) (w)
Email address: Birthdate: Click here to enter a date.
Occupation: Employer:
Who referred you to the clinic:
EMERGENCY CONTACT
Full name: Phone number:
Relationship to you:
FAMILY DOCTOR
Name: Phone:
Date of last appointment/physical: Click here to enter a date.
Health care number:
HEALTH INSURANCE PLAN
In order for us to direct bill your insurance company we also require a credit card on file which may be billed monthly for any amount that is not covered by your insurance/paid to us by another means.
Insurance Information
Company: ID/Certificate:
Policy/Group: Name of policy holder:
Credit Card Information
Name on card: Type of card:
Card number: Expiry date: Click here to enter a date.
HEALTH HISTORY
Please list any drugs or medications you are taking:
Please list any vitamins/herbs/homeopathics/other you are taking:
Do you smoke:
· If yes, how many per day: Do you drink alcohol:
· If yes, how many per week:
Have you had any prior surgeries:
Have you had any prior hospitalizations:
Please check current or previous problem/concerns:
General Symptoms / Muscles & Joints / E.E.N.T / RespiratoryHeadache ☐ / Swollen joints ☐ / Blurred vision ☐ / Chronic cough ☐
Migraine ☐ / TMJ R☐L ☐ / Double vision ☐ / Difficulty breathing ☐
Sweats ☐ / Neck pain R☐L ☐ / Earache ☐ / Spitting up blood ☐
Fainting ☐ / Shoulder pain R ☐ L ☐ / Deafness ☐ / Chest pain ☐
Dizziness ☐ / Elbow pain R☐L ☐ / Ringing in the ears ☐ / Tuberculosis ☐
Numbness ☐ / Wrist pain R ☐ L ☐ / Asthma ☐
Tingling ☐ / Hand pain R ☐ L ☐ / Sinus problems ☐
Loss of sleep ☐ / Mid back pain R ☐ L ☐ / Frequent colds ☐
Weakness ☐ / Low back pain R ☐ L ☐ / Difficulty swallowing ☐
Loss of strength ☐ / Hip pain R ☐ L ☐ / Enlarged lymph glands ☐
Persistent fatigue ☐ / Knee pain R☐L ☐ / Fever ☐
Weight loss ☐ / Ankle pain R☐L ☐ / Speech problems ☐
High cholesterol ☐ / Foot pain R☐L ☐
Swelling of ankles ☐
Fibromyalgia ☐
Cardiovascular / Gastrointestinal / Genitourinary / Skin
Bleeding disorder ☐ / Nausea ☐ / Difficulty urinating ☐ / Dry skin ☐
Heart/blood disease ☐ / Gallbladder issues ☐ / Kidney infection ☐ / Infectious skin disease ☐
Stroke ☐ / Diarrhea ☐ / Bed wetting ☐ / Rashes ☐
Phlebitis ☐ / Constipation ☐ / Kidney stones ☐ / Easily bruise ☐
Varicose veins ☐ / Vomiting ☐ / Blood in urine ☐ / Hives ☐
Low blood pressure ☐ / Belching/gas ☐ / Frequent urination ☐ / Itchy skin ☐
High blood pressure ☐ / Indigestion ☐ / Eczema/psoriasis ☐
Pacemaker ☐ / Ulcers ☐
Hemophilia ☐ / Jaundice ☐
Heat/cold intolerance ☐
Other
Breast lump/pain ☐
Diabetes ☐
Cancer ☐
Seizures ☐
Hepatitis ☐
HIV/AIDS ☐
FAMILY HISTORY
Have your grandparents, parents, siblings or children ever been diagnosed with any of the following:
High blood pressure ☐ / Thyroid problems ☐Hormone problems ☐ / Kidney disease ☐
Diabetes (Type I/II) ☐ / Stroke ☐
Heart disease ☐ / Osteoarthritis ☐
High cholesterol ☐ / Cancer ☐
Mental illness ☐ / Neurological condition (e.g., MS, Parkinson’s) ☐
Depression ☐ / Rheumatoid arthritis ☐
Other Click here to enter text. / Breathing/lung problems (e.g., asthma) ☐
I do not know my family medical history ☐
FEMALES ONLY
Are you currently pregnant:
Number of pregnancies: Number of children:
Are you currently taking any pharmaceutical forms of birth control:
Do you experience:
Severe menstrual cramps ☐ / Loss of menstruation ☐ / Hot flashes ☐ / Irregular cycles ☐REASON FOR TODAYS VISIT
Primary complaint(s):
When did your complaint begin:
Rate your complaint (0=no pain, 10=excruciating pain):
Describe the severity: Describe the frequency:
Is your complaint worse in the: Is your complaint:
What makes your complaint better:
What makes your complaint worse:
POLICIES & ACCOUNT INFORMATION
Our primary goal is to work towards the resolution of your current condition as quickly as possible through excellent health care and patient education while helping to prevent you from experiencing this condition again.
We will always give a thorough explanation of what we have found in our history and physical exam; explain the condition we believe you to be suffering from, as well as the treatment options available to you, the expected outcome and any risks involved. Always feel free to ask questions at any stage of your treatment; good communication is an important part of the treatment and prevention process at the clinic. I hereby authorize the health care professionals at Dr. Katherine MacAdam Chiropractic Inc., with my prior knowledge, to release or to obtain any health information from my other health care providers as may be required for the management of my case.
In an effort to better serve our patients, 24 hours’ notice of cancellation is requested. In the event of a missed appointment or insufficient notice of cancellation, the fee for that appointment will be billed to your account.
All fees are due at the time services are rendered unless other arrangements have been made. Fees are subject to change without notice. Acceptable methods of payment are cash, cheque, debit Mastcard or Visa. For your convenience, we direct bill most insurance companies. If you have coverage through any other personal health insurance, company plan or any other third party, you are responsible for payment and a receipt will be issued to you for reimbursement.
I have read, understand and agree to the policies of this clinic described above. I have also had an opportunity to ask questions about these policies. I also understand that these policies may be subject to change without notification.
Patient signature: Date: Click here to enter a date.
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