Dear Prospective Patient,
In order to save time during your initial visit, this file contains a copy of the new
patient intake forms for Flamborough Health Clinic. There should be a total of 4
pages, after this page, of forms. Please complete them as thoroughly as possible.
To schedule your appointment, or should you need further clarification please
contact us at 905-481-0731.
Thank you for considering Flamborough Health Clinic. I look forward to working with
you to achieve your health goals.
Sincerely,
Jared Wilbrink BSc, DC
Patient File:
Date:
New Patient Form
Please complete this form completely. All information provided will be kept strictly confidential.
Title
Last Name
Personal Information
Date of Birth
First Name
YYYY/MM/DD
Gender
Female
Marital Status
M
S
W
D
Com Law
Address
City
Province
Home #
Postal Code
Cell #
Email address
May we contact you via email to remind you of appointments and notify you of up-to-date health and clinic information?
Emergency Contact
Home #
How did you hear about us?
Medical Contacts
Male
Middle Initial
Website
Presentation
Phone #
Reason for last visit
Other
Date of last visit
OHIP #
May we contact your family physician to discuss or update your case?
Previous Chiropractor
Yes
Exp date
YYYY/MM/DD
YYYY/MM/DD
No
Reason for last visit
Reason for consulting our office today
Preventative or wellness type care
Chronic condition
New condition
MVA
WSIB
Current Health History
Current condition
When did this condition begin?
Has this occurred before?
Other doctors/therapists seen for this condition
Yes
Yes
If yes, when?
No
Who?
No
When?
Medications or treatments tried for this condition
Severity of Pain at its worst 1=best 10=worst
1
Severity of Pain now
3
4
5
6
7
8
9
10
3
4
5
6
7
8
9
10
1=best 10=worst
1
905-481-0731
2
2
No
Cell #
A patient, who?
Family Doctor
Yes
245 Hwy 8 RR1 Dundas ON
www.flamboroughhealth.com
Current Health History (continued)
Please use the diagram below to indicate the problem areas
A=Achy
S=Stabbing
B=Burning
Diagram Key:
P=Pins & Needles
N=Numbing
T=Stiff & Tight
Medications you currently take (if you prefer, you may ask the receptionist to photocopy your list):
Natural supplements you currently take (if you prefer, you may ask the receptionist to photocopy your list):
Past and Family Health History
Do you smoke?
Yes,_______packs/day
No
What is your average weekly alcohol consumption?__________
Please list any hospitilizations or surgical procedures, with the year that you had them
Please list any previous traumas (ie. MVA, work injuries, sports injuries, childhood traumas) with the year
Do you have a family history of any of the following conditions?
Osteoporosis
905-481-0731
Cancer
Diabetes
Heart disease
Hypertension
245 Hwy 8 RR1 Dundas ON
Obesity
Arthritis
Stroke
Other
www.flamboroughhealth.com
This list of conditions may seem unrelated to the purpose of your appointment. However,
these problems may influence your response to care.
Please place a 'C' by any conditions that you currently have and a 'P' by any conditions you have had in the past.
Headaches
Hand pain
Heel pain
Neck pain
Shoulder pain
Hip pain
Foot pain
Mid back pain
Elbow pain
Knee pain
Jaw pain/clicking
Low back pain
Wrist pain
Ankle pain
General pain/stiffness
Numbness in arm/hand
Dizziness
Anxiety/Depression
Fainting
Numbness in leg/foot
Forgetfulness
Paralysis
Convulsions
Muscle spasticity
Muscle weakness
Musculoskeletal
General Health History
Nervous System
Viscera
Heart problems
Blood vessel problems
Lung problems
Lymphatic problems
EENT problems
Liver problems
Stomach problems
Esophagus problems
Digestive tract problems
Pancreas problems
Appendix problems
Spleen problems
Kidney problems
Bladder problems
Female organ problems
Male organ problems
Immune system problems
Skin problems
Communicable disease
Neurologic problems
Muscle problems
Bone problems
General
Fatigue
Allergies
Fever
Weight gain
Weight loss
Poor sleep
Personal satisfaction with diet
Do you have a regular exerise program?
Highly satisfied
Yes
No
Satisfied
Lifestyle stress levels
Dissatisfied
High
Highly dissatisfied
Moderate
Very little
I certify that the information herein is, to the best of my knowledge, true and correct and I understand that it is
my responsibility to inform Flamborough Health Clinic of any changes. I hereby authorize the Doctor to examine
me understanding that such examinations can periodically lead to aggravation of symptoms. Further, I
understand that information provided on this form and in the consultation/examination are part of my health
record and are confidential.
Signature:_____________________________________________ Date:___________________________
Patient or Parent/Guardian
905-481-0731
245 Hwy 8 RR1 Dundas ON
www.flamboroughhealth.com
Patient's Name____________________________________________________ Date_____________________File___________
Nutrition Survey
This questionnaire has been designed to give the doctor information about how your diet may be affecting your symptoms and your
general health and well-being. Please answer each question by checking the box that applies to you. Please be as thorough
as possible.
1. Of the food products I consume,
10% or less is store bought pre-packaged processed food.
25% or less is store bought pre-packaged processed food.
50% or less is store bought pre-packaged processed food.
75% or less is store bought pre-packaged processed food.
most is store bought pre-packaged processed food.
9. I attempt to reduce my intake of foods with added
sugar (eg. foods that have sugar as one of the first
ingredients):
yes
no
I never pay attention to that.
2. I eat commercially prepared food
several times daily.
daily.
several times weekly.
weekly.
occasionally.
10. I drink mostly (choose up to three)
water
coffee
tea
milk
soft drinks
juice
pure fruit or vegetable juice
energy drinks
sport drinks (eg. Gatorade)
other __________
3. I consume an average of
1 or less servings* of fruit per day.
2 to 3 servings of fruit per day.
4 to 5 servings of fruit per day.
more than 5 servings of fruit per day.
11. My protein intake consists of
mostly farm raised animal meat.
mostly vegetarian sources (vegetables, soy).
mostly fresh fish.
mostly wild game.
mostly grass-fed animal meat.
a mixture of the above.
4. I consume an average of
1 or less servings* of vegetables per day.
2 to 3 servings of vegetables per day.
4 to 5 servings of vegetables per day.
more than 5 servings of vegetables per day.
5. I consume an average of
1 or less servings** of whole grains per day.
2 to 4 servings of whole grains per day.
5 to 7 servings of whole grains per day.
more than 7 servings of whole grains per day.
6. I consume an average of (eg. white bread, pasta or rice)
1 or less servings** of refined grains per day.
2 to 4 servings of refined grains per day.
5 to 7 servings of refined grains per day.
more than 7 servings of refined grains per day.
7. I attempt to follow a low fat diet:
yes
no
I consume healthy fats and avoid unhealthy ones.
8. My food is cooked in or baked with
olive oil, butter, coconut oil or lard.
vegetable oil, canola oil, sunflower oil, safflower oil, corn oil
or soy oil.
* 1 serving = 125 ml, ½ cup, approx. 1 handful
** 1 serving = 1 slice of bread, ½ bagel, ½ cup rice or pasta
905-481-0731
12. I supplement with Omega Essential Fatty Acids
never.
rarely.
during the winter months.
most days.
always.
13. I supplement with
less than 400 IU of vitamin D per day.
400 to 1000 IU of vitamin D per day.
1000 or more IU of vitamin D per day.
2000 or more IU of vitamin D per day.
3000 or more IU of vitamin D per day.
4000 or more IU of vitamin D per day.
14. Relative to my ‘early twenties’ weight, I am
5 or more pounds lighter.
within +/- 5 pounds.
5 to 10 pounds heavier.
10 to 20 pounds heavier.
20 to 50 pounds heavier.
more than 50 pounds heavier.
245 Hwy 8 RR1 Dundas ON
www.flamboroughhealth.com