PATIENT ENTRANCE FORM Personal Information Date: Name: Birth Date (D/M/Y): Age: Sex (M/F):

Address: City: Prov:

Postal Code: Home #: Work #: Cell #:

Email: Marital Status: M / W / D / S

Occupation: Employer:

Insurance company: Policy #:____________Member ID#:_________________

Emergency contact: Relationship: Contact #:

How did you hear about our office?

Referred: □ Dental patient: □ Newspaper: □ Sign: □

If referred, who may we thank for referring you :

Current Health Condition

Purpose of this appointment:

Other health professionals seen:

Name of other professionals:

Type of treatment:

Results:

Any medications for this condition:

Xrays taken: Yes □ No □ Date: Results:

When did the condition begin:

Has this condition occurred before: Yes □ No □ If so, when:

Medical information Previous chiropractic care: Yes □ No □ If yes, chiropractor’s name:

Chiropractor’s address: Chiropractor’s phone #:

Previous Chiropractic techniques used:

Family medical doctor: MD’s phone #:

Last checkup date: Last physical date:

Current medications:

Past medications:

CASE HISTORY FORM

Progressive Chiropractic Centre 4-2165 Grosvenor St. Oakville, ON L6H 7K9 905.849.3505

Patient Name: Date:

(TO BE COMPLETED BY PATIENT) Mark the areas on your body where you feel your pain. Include all affected areas. If the pain radiates, draw an

arrow from where it begins to where it ends. Use the appropriate symbol(s) below. Ache > > > > > > Numbness = = = = Pins & Needles O O O O Burning X X X X Stabbing * * * * * Throbbing ~ ~ ~ ~ ~ ~ Tightness # # # # Scars + + + + + + Past broken bones ? ? ? ? ?

On a scale of 0 to 10, using the line below, please mark with an “X” the level of your pain today.

A “0” indicates no pain while a “10” indicates the worst pain you have ever experienced. | ----- - |

0 10

(TO BE COMPLETED BY DOCTOR) 1. Chief Complaint:

2. When did it happen: 3. How:

4. Describe it: 5. Radiation: 6. Anything help it: 7. Anything makes it worse: 8. Time of day it hurts: ______ 9. How often: 10. How long it last: 11. Has it happened before: 12. How did happen first: ______ 13. Any recent bowel/bladder changes: 14. Any pain at night or night sweats: 15. Social history (Caffeine, alcohol, drugs, exercise, diet, stress):

______

16. Additional health conditions/remarks:

Treatment Questionnaire There are many types of patients and many types of care that can be rendered to a patient. Please check the following responses that best reflect the type of care you desire so that we can give you the type of care that you want. Select all that are appropriate for you.

I prefer to have as much work on my problem done as possible in the office instead of at home.

I prefer to take as much responsibility as possible for my health care.

I am greatly interested in understanding about my condition.

I don’t really care to understand much about my condition and just want to get

better.

I want to do as much as I can to assist in my health care and am willing to change my:

Diet Nutritional support Exercise Lifestyle

I am interested in my overall health and want to learn more on how to stay

healthy.

I just want my current problem helped. The following is a partial list of the different procedures we might employ in our office to help improve your health. Please check all that you are interested in and draw a line through any that you are not interested in at this time.

All of the following at the doctor’s discretion

Anti-aging Cranial technique Diet modification Exercise – cardiovascular

Exercise – strength Exercise – motion Food sensitivity Home exercise

Spinal manipulation Nutritional guidance Physical therapy

___________________________________ ________________ Name: Date:

PAST HEALTH HISTORY

Please indicate whether you have experienced any of the following: N = Now P = Past Musculoskeletal Gastrointestinal Neck pain Stomach cramps Sinus congestion Mid back pain Low appetite Loss of tastes Low back pain High appetite Loss of smell Shoulder pain Frequently thirsty Difficulty chewing Elbow pain Frequent nausea Recent dental work Wrist pain Nausea after eating Recent illness Hand pain Nausea relieved by eating Hip pain Vomiting Male/Female Knee pain Diarrhea Menstrual irregularity Ankle pain Constipation Menstrual cramps Foot pain Hemorrhoids Heavy flow Jaw pain Liver problems Mood swings with period Clicking jaw Gallbladder problems Vaginal pain/infection Muscle pain/stiffness Weight problems Breast pain/lumps Muscle cramps Gas/bloating Pregnant Yes ٱ No ٱ Pain with walking Heartburn Not sure ٱ Arthritis Dark/bloody stool Date of last period: Crohn’s disease Date of last PAP: Nervous system Colitis Date of last mammogram: Nervousness Irritability Genito-urinary Numbness Bladder problems Family history Paralysis Painful urination (Please indicate whether you Dizziness Excessive urination or any family member has Loss of memory Difficulty urinating experienced any of the Confusion Frequent night urination following diseases): Depression Discoloured urine Pneumonia Fainting episodes Rheumatic fever Convulsions Cardiovascular/Respiratory Whooping cough Tingling Chest pain/tightness Anemia Weakness Shortness of breath Measles Loss of balance High/low blood pressure Mumps Cold hands/feet Irregular heartbeats Chicken pox Heart problems Diabetes General Lung problems/Congestion Cancer Fatigue Varicose veins Heart disease Allergies Ankle swelling Thyroid disease Can’t fall asleep Stroke Asthma Can’t stay asleep Arthritis Fever EENT Epilepsy Headaches Vision problems Mental disorders Migraines Dental problems Eczema/Psoriasis Stressed Sore throat AIDS/HIV Ear aches/infection Alcohol abuse Hearing difficulties Drug abuse

Progressive Chiropractic Centre

Dr. Erik Nabeta & Dr. Christine Chang 4-2165 Grosvenor St. Oakville, ON L6H 7K9

905.849.3505

INFORMED CONSENT FOR CHIROPRACTIC

Please read carefully

It is important for you to consider the benefits, risks and alternatives to the treatment options offered by your chiropractor and to make an informed decision about proceeding with treatment. Chiropractic treatment includes adjustment, manipulation and mobilization of the spine and other joints of the body, soft-tissue techniques such as massage, and other forms of therapy including, but not limited to, electrical or light therapy and exercise. Benefits

Benefits include:

x Effective treatment for neck, back and other areas of the body caused by nerves, muscles, joints and related issues. x Relieve headache x Relieve altered sensation x Relieve muscles stiffness and spasm x Increase mobility and stability x Increase overall body function and reduce or eliminate the need for drugs or surgery.

Risks

The risks associated with chiropractic treatment vary according to each patient’s condition as well as the location and type of treatment.

The risks include: ● Temporary worsening of symptoms – One of three results usually occurs: Condition improves; No change happens; Conditions worsens. If it worsens, this will last only a few hours to a few days.

● Skin irritation – Skin irritation may occur in association with the use of some types of electrical or light therapy. Skin irritation should resolve quickly.

● Sprain or strain – Typically, a muscle or ligament sprain or strain will resolve itself within a few days or weeks with some rest, protection of the area affected and other minor care.

● Rib fracture – While rib fractures have been rarely reported with chiropractic care, the chances are minimal. All precautions will be taken to avoid this. If you are not comfortable with the treatment, alternative methods can be provided.

● Injury or aggravation of a disc – Patients who already have a degenerated or damaged disc may or may not have symptoms. They may not know they have a problem with a disc. They also may not know their disc condition is worsening because they only experience back or neck problems once in a while.

Chiropractic treatment should not damage a disc that is not already degenerated or damaged, but if there is a pre-existing disc condition, chiropractic treatment, like many common daily activities, can possibly aggravate the disc condition.

The consequences of disc injury or aggravating a pre-existing disc condition will vary with each patient. In the most severe cases, patient symptoms may include impaired back or neck mobility, radiating pain and numbness into the legs or arms, impaired bowel or bladder function, or impaired leg or arm function. Surgery may be needed.

● Stroke – Blood flows to the brain through two sets of arteries passing through the neck. These arteries may become weakened and damaged, either over time through aging or disease, or as a result of injury. A blood clot may form in a damaged artery. All or part of the clot may break off and travel up the artery to the brain where it can interrupt blood flow and cause a stroke.

Many common activities of daily living involving ordinary neck movements have been associated with stroke resulting from damage to an artery in the neck, or a clot that already existed in the artery breaking off and travelling up to the brain.

Progressive Chiropractic Centre

Dr. Erik Nabeta & Dr. Christine Chang 4-2165 Grosvenor St. Oakville, ON L6H 7K9

905.849.3505

Although chiropractic treatment has been loosely associated with stroke in the past, the association occurs extremely infrequently. These occurrences may be explained because an artery was already damaged and the patient was already progressing toward a stroke when the patient consulted the chiropractor. Present medical and scientific evidence does not establish that chiropractic treatment causes either damage to an artery or stroke.

Alternatives

If you are uncomfortable with any treatment techniques discussed with the chiropractor, alternative gentle techniques, such as activator, mobilization without thrust, and/or stretching/exercises can be provided.

Questions or Concerns

You are encouraged to ask questions at any time regarding your assessment and treatment. Bring any concerns you have to the chiropractor’s attention. If you are not comfortable, you may stop treatment at any time.

Examination Consent

I acknowledge and understand that in order to determine the state of my health and suitability of my case for chiropractic care I must complete a thorough evaluation.

I hereby request and consent to such an examination by Dr. Nabeta and Dr. Chang. I have had the opportunity to discuss the nature of the evaluation that I will receive and understand that some procedures or tests may produce discomfort at the

time they are performed or afterwards. ____________________________________ Name (Please Print) ____________________________________ Date: ______________ 20____ Signature of patient (or legal guardian) ____________________________________ Date: _______________20____ Signature of Chiropractor

DO NOT SIGN THIS PART OF THE FORM UNTIL YOU MEET WITH THE CHIROPRACTOR

I have discussed with the chiropractor the assessment of my condition and the treatment plan. I understand the nature of the treatment to be provided to me. I have considered the benefits and risks of treatment, as well as the alternatives to

treatment. I hereby consent to chiropractic treatment as proposed to me. ____________________________________ Name (Please Print) ____________________________________ Date: ______________ 20____ Signature of patient (or legal guardian) ____________________________________ Date: _______________20____ Signature of Chiropractor Please be involved in and responsible for your care. Inform your chiropractor immediately of any change in your condition.

Progressive Chiropractic Centre

Erik Nabeta, D.C. 4-2165 Grosvenor St. Oakville, ON L6H 7K9

905.849.3505 drnabeta@progressive-health.ca

www.progressive-health.ca

Patients with Extended Health Care Insurance All patients are recommended to check their insurance for coverage of CHIROPRACTIC, MASSAGE THERAPY, CUSTOM ORTHOTICS and COMPRESSION STOCKINGS. The following questions should be asked when calling your insurance company regarding coverage.

Chiropractic

What is the maximum amount paid per visit and per calendar/benefit year for Chiropractic?

Per Visit: $_________________ Per Calendar Year: ________________ % _____________

When does the coverage begin? x After a co-payment or deductible � How much? _____________________ x After how many visits _____________________

Massage Therapy

What is the maximum amount paid per visit and per calendar year for Massage Therapy?

Per Visit: $_________________ Per Calendar Year: ________________ % _____________

Do you require a referral from a: Chiropractor: � MD: �

Orthotics / Compression Stockings Do you have coverage for Custom-Made Foot Orthotics Yes � No � Compression Stockings Yes � No �

If yes, what is the amount covered for orthotics? $_______ per calendar OR benefit year.

If yes, what is the amount covered for compression stockings? $_______ per calendar OR benefit year.

What is the required compression under your insurance company’s guideline?

Do you require a referral for Custom Orthotics/Compression stockings from a:

Chiropractor: � Medical Doctor: � Podiatrist/Chiropodist: � Other: �

Who is eligible to dispense the orthotics?

Chiropractor: � Medical Doctor: � Podiatrist/Chiropodist: � Other: �

Who is eligible to dispense the compression stockings?

Chiropractor: � Medical Doctor: � Other: �

HELPFUL HINTS

Always make sure you get the name of the person at the insurance company to whom you spoke to or who gave you this information so you can reach this person in the case of a discrepancy. If you require assistance in contacting your insurance company, please call us at (905) 849-3505 and Dr. Nabeta will gladly assist you. Insured Employer Name: _________________________________________________________ Insurance Company Name: _______________________________________________________ Group Number: _______________________ ID Number :_______________________________