Patient Name: ______Date:______

Date of Birth: _____/___/___ (yyyy/mm/dd) Gender: Male Female

Address: ______

City: ______Postal Code:______

Phone: Home: (____) ______Work: (____) ______

Occupation: ______

May we leave messages relating to your visits: Home - Y N Work - Y N

Email Address: ______

Emergency Contact: ______Phone (____) ______

Number of children: ______

Name / Age

Medical doctor’s name: ______Medical doctor’s telephone: ______

Date of last visit to medical doctor: ______Date of last physical: ______

Type of Injury

Is this a workplace Safety and Insurance Board Injury? Yes No

(If you answered “No” to the above question, you do not need to fill in the following information)

Social Insurance Number: ______WSIB claim number: ______

Date of Accident: ______Employer’s Name: ______

Employer’s address and telephone: ______

Are your injuries related to a motor vehicle case? Yes No

(If you answered “No” to the above question, you do not need to fill in the following information)

Date of accident: ______Insurer’s name: ______

Policy or claim #: ______

Insurer’s address and telephone: ______

Medical History

Please indicate any serious conditions, illnesses or injuries, and any hospitalizations; along with approximate dates.

______

Please list any known allergies (medicines, environmental, etc.):

______

Please list all current medications (prescription, over-the-counter, vitamin, herbs, homeopathic, etc.):

______

Please list past prescription medications.

______

Health Concerns

What is your primary health concern?

______

How long have you had this condition? ______

What specialist(s) have you seen, if any? ______

How has this condition been treated until now? ______

Can you trace the origin of the present illness to any particular circumstances, accident, illness, incident, mental upset or unusual stress in your life? If yes, please explain. ______

Additional Health Concerns and Health Goals

What else would you like to see changed in your health? List all other health concerns or goals in order of importance to you. Indicate the month and year each particular health concerned started, if possible.

Health Concern/Goal / Month/Year / Present Treatment/Comments
1
2
3
4
5

How would you describe your general state of health? Excellent Good Fair Poor

How long has it been since you experienced excellent health? ______

How did you hear about us?

Friend or Relative Yellowpages Other

Signage Newspaper

Internet/Facebook Public Outreach

Consent

I agree and understand that I am responsible for all charges to my visit.

Date: ______Signature: ______

Date: ______Guardian (if under 18): ______