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 5
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
Name ______________________________________________
Date __________________________
Modified Örebro Musculoskeletal Pain Questionnaire
These questions and statements apply if you have aches or pains, such as back, shoulder or neck pain. Please read and
answer the questions carefully. Do not take long to answer each question; however, it is important that you answer every
question. There is always a response for your particular situation.
1. Where do you have pain? Check all appropriate sites.
Neck
Shoulder
Arm
Leg
Other __________________
Upper back
Lower back
2. How much of a burden is it to perform all the things you need to do in a normal day? (0 = no burden, 10 = very large
burden)
0
1
2
3
4
5
6
7
8
9
10
3. How often would you say that you have experienced pain episodes, on average, during the past three months?
(0 = never, 10 = always)
0
1
2
3
4
5
6
7
8
9
10
4. Based on all the things you do to cope, or deal with your pain, on an average day, how much are you able to
decrease it? (0 = can't decrease it at all, 10 = can decrease it completely)
0
1
2
3
4
5
6
7
8
9
10
5. How tense or anxious have you felt in the past week? (0 = absolutely calm and relaxed, 10 = as tense and anxious as I've
ever felt)
0
1
2
3
4
5
6
7
8
9
10
6. How much have you been bothered by feeling depressed in the past week? (0 = not at all, 10 = extremely)
0
1
2
3
4
5
6
7
8
9
10
7. What do you think is the risk that your current pain or problem will not improve? (0 = no risk, 10 = very large risk)
0
1
2
3
4
5
6
7
8
9
10
8. In your estimation, what are the chances that you will be able to work in six months? (0 = no chance, 10 = very large
chance)
0
1
2
3
4
5
6
7
8
9
10
9. Think of your life; how satisfied are you with your current situation? (0 = not satisfied at all, 10 = completely satsified)
0
1
2
3
4
5
6
7
8
9
10
Here are some of the things that other people have told us about their pain. For each statement, choose one number from
0 to 10 to say how much physical activities, such as bending, lifting, walking or driving, would affect your pain.
10. Physical activity makes my pain worse. (0 = completely disagree, 10 = completely agree)
0
1
2
3
4
5
6
7
8
9
10
11. An increase in pain is an indication that I should stop what I'm doing until the pain decreases. (0 = completely
disagree, 10 = completely agree)
0
1
2
3
4
5
6
7
8
9
10
12. I should not do my normal work with my present pain. (0 = completely disagree, 10 = completely agree)
0
1
2
3
4
5
6
7
8
9
10
Here is a list of five activities. Choose the one number that best describes your current ability to participate in each of these
activities.
13. I can do light work for an hour. (0 = can't do it because of a pain problem, 10 = can do it without pain being a problem)
0
1
2
3
4
5
6
7
8
9
10
14. I can walk for an hour. (0 = can't do it because of a pain problem, 10 = can do it without pain being a problem)
0
1
2
3
4
5
6
7
8
9
10
15. I can do ordinary household chores. (0 = can't do it because of a pain problem, 10 = can do it without pain being a problem)
0
1
2
3
4
5
6
7
8
9
10
16. I can do the weekly shopping. (0 = can't do it because of a pain problem, 10 = can do it without pain being a problem)
0
1
2
3
4
5
6
7
8
9
10
17. I can sleep at night. (0 = can't do it because of a pain problem, 10 = can do it without pain being a problem)
0
1
2
3
4
5
6
7
8
9
10