Medical Assessment Form

3

MEDICAL ASSESSMENT FORM

(Please Print)

PATIENT INFORMATION

Patient’s last name: / First: / Middle: / q Mr.
qMrs. / q Miss
q Ms. / Date of Birth: dd/mm/yyyy
Street Address: / Unit or Apartment #: / City: / Postal Code:
Sex: / Home Phone Number: Cell Phone Number: / Work Phone Number:
q M q F / ( ) ( ) / ( )
E-Mail Address:
Emergency Contact: / Phone: ( )

MEDICAL INFORMATION

Patient Name: / Date Of Birth: / Occupation:
How did you hear about us?
q  Yellow Pages
q  Web Site
q  Doctor Referral (Dr. ______so we can thank them)
q  Patient Referral ______
q  Other
Family Doctor: / Phone Number: / Practice Location:
( )
Current Medications:
Please list and date any Surgeries:
Please list the presence of any internal pins, wires and artificial joints:
Is this Condition: / q Motor Vehicle Accident / q WSIB / q Sports Injury / q Other: / ______
What is your Chief Complaint:
Any other areas of Concerns:
How long have you had your present pain?
Did your present pain begin with a specific incident?
q  No
q  Yes (if yes please explain)
Please rate your pain level on the chart below:
No Pain Very Painful
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
Have you had this problem before?
q  No
q  Yes (if yes, how often and how long does the pain last?)
INDICATE AREAS OF PAIN OR DISCOMFORT
Mark the areas on the bodies where you feel the described sensations.
Indicate areas of:
Numbness ))))
Pins & Needles OOOO
Burning XXXX
Aching ****
Stabbing //// /

MEDICAL HISTORY

Cardiovascular
q  High Blood Pressure
q  Low Blood Pressure
q  Chronic Heart Failure
q  Heart Disease
q  Myocardial Infarction
q  Phlebitis
q  Cardio-Vascular Accident
q  Stroke
q  Pacemaker
q  Varicose Veins
q  Blood Clots
q  Osteoarthritis
q  Lymphedema
q  Other: ______/ Digestive
q  Constipation
q  Gas/Bloating
q  Nausea/Vomiting
q  Irritable Bowel Syndrome
q  Liver/Gall Bladder
q  Kidney/Bladder
Nervous System
q  Herpes/Shingles
q  Numbness/Tingling
q  Chronic Pain
q  Fatigue
q  Sleep Disorder
q  Loss of Sensation
q  Other: ______/ Skin
q  Allergies (anaphylactic)
q  Rashes
q  Athletes Foot
q  Warts
q  Cold Sores
q  Eczema/Psoriasis
q  Other: (contagious)
______
Reproductive
q  Pregnancy (trimester___)
q  PMS
q  Other: ______
Respiratory
q  Chronic Cough
q  Bronchitis
q  Shortness of Breath
q  Asthma
q  Emphysema
q  Smoking
q  Other: ______
Infectious Diseases
q  Hepatitis
q  Tuberculosis
q  HIV
q  Other: ______/ Musculo-Skeletal
q  Bone or Joint Disease
q  Tendonitis
q  Bursitis
q  Fractures
q  Osteoporosis
q  Osteoarthritis
q  Arthritis
q  Sprains/Strains
q  Swelling
q  Stiffness
q  Headaches
q  Migraines
q  Spasms/Cramps
q  Pain (check area):
_Jaw _Neck _Shoulder _Elbow _Wrist _ Hip _Knee _Ankle _Back _Foot _Toes / Other
q  Drug/Alcohol addiction
q  Nicotine/Caffeine addiction
q  Diabetes
q  Vision/Hearing Loss
q  Cancer
q  Epilepsy
q  Allergies (please list)
q  Other: ______
Release of Medical and Other Information

Release of Information:

I hereby authorize THL Management Inc. (Total Health Link). and/or its employees or agents to be permitted to obtain and review copies of all medical, hospital, clinical, and practitioner’s notes; employment, vocational, and insurance documents, including full and final or other releases, and any other related records or documents, and to share or discuss pertinent information with appropriate qualified medical & paramedical professionals or others involved in my treatment, rehabilitation, claims or representation. I agree that a photocopy of this authorization be accepted if necessary.

Dated this ______day of______,20______.

______

Patient Signature (Legal Guardian) Name (Please Print)

Total Health Link 3015C New Street, Burlington, ON L7R 1K3 905.333.4888

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