PATIENT INFORMATION:
Name: Mr., Mrs., Miss, Ms., Dr.____________________________________________________________
Address: ______________________________________________________________________________
City:______________________________________________ Postal Code: ________________________
Phone number: Home: ______________________________ Cell: ______________________________
Bus: ______________________________
Emergency contact name: ___________________________________ Phone: ______________________
Email Address __________________________________________________________________________
Date of Birth: ______/ ______/ ______ Age: __________ Gender: ____________
(mo.) (day) (yr.)
Occupation:____________________________________________________________________________
Marital Status: _____M _____S _____W _____D
Spouse’s Name: ______________________________________________ No. of children: ____________
Were your referred to this clinic? ______ Yes ______ No
If yes, by whom?________________________________________________________________________
If no, how did you hear about this clinic? ____________________________________________________
By providing my email address, I give consent to receive updates and information about Momentum Healing Arts Centre. Momentum Healing Arts Centre will never give out or sell any patient addresses.
Is your pain a result of a car or work accident? _______ yes _______ no
If yes, when was the accident: ____________________________________________Family Physician: ____________________________________________________________________Address: __________________________________________ Postal Code:______________________
Phone number: ____________________________________ Fax #: __________________________
T1065 CANADIAN PLACE, UNI #101MISSISSAUGA, ON
L4W 0C2
DR. ASTRID TRIM
DR. COLLEEN PRENDERGAST
H O LI S T I C H E AL I N G AR T SAncient Theory Modern Methods
1065 CANADIAN PLACE, UNIT #101MISSISSAUGA, ON
L4W 0C2
DR. ASTRID TRIM DR. PAUL RANKIN DR. TARA BROWN
PATIENT INFORMATION:Name: Mr., Mrs., Miss, Ms., Dr.____________________________________________________________
Address: ______________________________________________________________________________
City:______________________________________________ Postal Code: ________________________
Phone number: Home: ______________________________ Cell: ______________________________
Bus: ______________________________
Emergency contact name: ___________________________________ Phone: ______________________
Email Address __________________________________________________________________________
Date of Birth: ______/ ______/ ______ Age: __________ Gender: ____________ (mo.) (day) (yr.)
Occupation:____________________________________________________________________________
Marital Status: _____M _____S _____W _____D
Spouse’s Name: ______________________________________________ No. of children: ____________
Were your referred to this clinic? ______ Yes ______ No
If yes, by whom?________________________________________________________________________
If no, how did you hear about this clinic? ____________________________________________________
By providing my email address, I give consent to receive updates and information about Momentum Healing Arts Centre. Momentum Healing Arts Centre will never give out or sell any patient addresses.
Is your pain a result of a car or work accident? _______ yes _______ no
If yes, when was the accident: ____________________________________________
1
Family Physician: ____________________________________________________________________Address: __________________________________________ Postal Code:______________________
Phone number: ____________________________________ Fax #: __________________________
GENERAL HEALTH HISTORY: Please circle any condi ns or symptoms presently causing you problems. Please X those or symptoms which have been a health concern in the past.
GENERAL SYMPTOMS Blackouts
Headaches Migraines
Fever, Sweats ng
Dizziness Weight Loss
Loss of Sleep due to pain Convulsions
Numbness or Tingling in arms/legs Anxiety
Feelings of extreme stress
RESPIRATORYChronic cough
ng up phlegm or blood Chest pains
Shortness of breath
SKINRashes, eczema, itching
Bruising easily Dryness
Do you have any allergies? Yes No If so, to what ? ____________________
________________________________
MUSCLES & JOINTS Neck pain or ess
Mid back pain or Low back pain or Swollen & painful joints
Foot pain or injury Knee pain or injury
Shoulder pain or injury Arm/Forearm pain or injury
Wrist pain or injury Hand/finger pain or arthri s Weakness or loss of strength
Diagnosis of arthri s: What kind? __________________
EYES, EARS, NOSE, THROAT Blurry/double vision
Failing vision (one/both eyes) Eye pain
Deafness/Hearing loss Chronic earaches
Ringing/buzzing in one/both ears Asthma
Frequent colds/flus Sinus n
Enlarged lymph glands Enlarged thyroid
Abnormal thyroid on levels Slurred Speech
Difficulty swallowing
CARDIOVASCULARVaricose Veins
Swelling of the ankles Angina
Bleeding disorder High blood pressure Low blood pressure
High cholesterol Do you take medica on for these? Yes __________________ No ____
GASTROINTESTINALPoor appe
Indiges n Hiatus Hernia/Acid Reflux
Recurring Cons Chronic Diarrhea
Kidney Stones Gall bladder problems
Irritable Bowel Syndrome s /Crohns disease
Celiac disease Do you take medica on for
any of the above? Yes __ No __ If yes, what? __________________________
FOR WOMEN ONLYPainful menstr
Excessive flow Irregular cycle
Cramps or backaches History of breast cancer in family?
Yes ___________________ No _____ Are you menopausal?
Peri _____ Present _______Post _____ Are you on a Birth control pill?
Yes No Have you been diagnosed with osteoporosis
(low bone density)? Yes No
Number of pregnancies? ________ Number of children? ________
GENERAL QUESTIONS:
Have you ever been in a car accident? Yes No When? _____________________ Sleep Posture: circle all that apply: back stomach side Are you currently a smoker? Yes No Are you an ex-smoker? Yes No Do you take medica on on a regular basis? Yes No Please list your medica :
o For high blood pressure o For high cholesterol o For high/low thyroid o Blood thinners
_______________________ o Other medica :
_____________________ What is your current level of pain? x----------------------------------------------x 0 1 2 3 4 5 6 7 8 9 10 Please draw your pain on the figure:
H O LI S T I C H E AL I N G AR T SAncient Theory Modern Methods
1065 CANADIAN PLACE, UNIT #101MISSISSAUGA, ON
L4W 0C2
DR. ASTRID TRIM DR. PAUL RANKIN DR. TARA BROWN
PATIENT INFORMATION:Name: Mr., Mrs., Miss, Ms., Dr.____________________________________________________________
Address: ______________________________________________________________________________
City:______________________________________________ Postal Code: ________________________
Phone number: Home: ______________________________ Cell: ______________________________
Bus: ______________________________
Emergency contact name: ___________________________________ Phone: ______________________
Email Address __________________________________________________________________________
Date of Birth: ______/ ______/ ______ Age: __________ Gender: ____________ (mo.) (day) (yr.)
Occupation:____________________________________________________________________________
Marital Status: _____M _____S _____W _____D
Spouse’s Name: ______________________________________________ No. of children: ____________
Were your referred to this clinic? ______ Yes ______ No
If yes, by whom?________________________________________________________________________
If no, how did you hear about this clinic? ____________________________________________________
By providing my email address, I give consent to receive updates and information about Momentum Healing Arts Centre. Momentum Healing Arts Centre will never give out or sell any patient addresses.
Is your pain a result of a car or work accident? _______ yes _______ no
If yes, when was the accident: ____________________________________________
1
Family Physician: ____________________________________________________________________Address: __________________________________________ Postal Code:______________________
Phone number: ____________________________________ Fax #: __________________________
THE BOURNEMOUTH QUESTIONNAIRE
NAME__________________________ DATE_____________AGE_____Initials:______
The following scales have been designed to find out about your pain and how it is affecting you. Please answer ALL the scales by circling ONE number on EACH scale that best describes how you feel:
1. Over the past week, on average, how much would you rate your pain?No pain Worst pain possible0 1 2 3 4 5 6 7 8 9 10
2. Over the past week, how much has your pain interfered with your daily activities? (Housework, washing, dressing, walking, climbing stairs, getting in/out of bed/chair)No Pain Unable to carry out activity0 1 2 3 4 5 6 7 8 9 10
3. Over the past week, how much has your pain interfered with your ability to take part in recreational, social, and family activities?No pain Unable to carry out activity0 1 2 3 4 5 6 7 8 9 10
4. Over the past week, how anxious (tense, uptight, irritable, difficulty in concentrating/relaxing) have you been feeling?No Pain Extremely anxious0 1 2 3 4 5 6 7 8 9 10
5. Over the past week, how depressed (down in the dumps, sad, in low spirits, pessimistic, unhappy) have you been feeling?No pain Extremely depressed0 1 2 3 4 5 6 7 8 9 10
6. Over the past week, how have you felt your work (both inside and outside the home) has affected (or would affect) your pain?No pain Have made it much worse0 1 2 3 4 5 6 7 8 9 10
7. Over the past week, how much have been able to control (reduce/help) your pain on your own?No pain No control whatsoever0 1 2 3 4 5 6 7 8 9 10
---------------------------------------------------------------------------------------------------------------------------
OFFICE USE ONLY: SCORE_____/70 = _______%
H O LI S T I C H E AL I N G AR T SAncient Theory Modern Methods
1065 CANADIAN PLACE, UNIT #101MISSISSAUGA, ON
L4W 0C2
DR. ASTRID TRIM DR. PAUL RANKIN DR. TARA BROWN
PATIENT INFORMATION:Name: Mr., Mrs., Miss, Ms., Dr.____________________________________________________________
Address: ______________________________________________________________________________
City:______________________________________________ Postal Code: ________________________
Phone number: Home: ______________________________ Cell: ______________________________
Bus: ______________________________
Emergency contact name: ___________________________________ Phone: ______________________
Email Address __________________________________________________________________________
Date of Birth: ______/ ______/ ______ Age: __________ Gender: ____________ (mo.) (day) (yr.)
Occupation:____________________________________________________________________________
Marital Status: _____M _____S _____W _____D
Spouse’s Name: ______________________________________________ No. of children: ____________
Were your referred to this clinic? ______ Yes ______ No
If yes, by whom?________________________________________________________________________
If no, how did you hear about this clinic? ____________________________________________________
By providing my email address, I give consent to receive updates and information about Momentum Healing Arts Centre. Momentum Healing Arts Centre will never give out or sell any patient addresses.
Is your pain a result of a car or work accident? _______ yes _______ no
If yes, when was the accident: ____________________________________________
1
Family Physician: ____________________________________________________________________Address: __________________________________________ Postal Code:______________________
Phone number: ____________________________________ Fax #: __________________________
H O LI S T I C H E AL I N G AR T SAncient Theory Modern Methods
1065 CANADIAN PLACE, UNIT #101MISSISSAUGA, ON
L4W 0C2
DR. ASTRID TRIM DR. PAUL RANKIN DR. TARA BROWN
PATIENT INFORMATION:Name: Mr., Mrs., Miss, Ms., Dr.____________________________________________________________
Address: ______________________________________________________________________________
City:______________________________________________ Postal Code: ________________________
Phone number: Home: ______________________________ Cell: ______________________________
Bus: ______________________________
Emergency contact name: ___________________________________ Phone: ______________________
Email Address __________________________________________________________________________
Date of Birth: ______/ ______/ ______ Age: __________ Gender: ____________ (mo.) (day) (yr.)
Occupation:____________________________________________________________________________
Marital Status: _____M _____S _____W _____D
Spouse’s Name: ______________________________________________ No. of children: ____________
Were your referred to this clinic? ______ Yes ______ No
If yes, by whom?________________________________________________________________________
If no, how did you hear about this clinic? ____________________________________________________
By providing my email address, I give consent to receive updates and information about Momentum Healing Arts Centre. Momentum Healing Arts Centre will never give out or sell any patient addresses.
Is your pain a result of a car or work accident? _______ yes _______ no
If yes, when was the accident: ____________________________________________
1
Family Physician: ____________________________________________________________________Address: __________________________________________ Postal Code:______________________
Phone number: ____________________________________ Fax #: __________________________
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