Emergency New Patient Paperwork

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Name*
First Last
Birthdate*
Date Format: MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email Address*
Do you give consent to receive any future electronic messages?*
- Yes
- No
Occupation*
Work Phone
Were you referred by anyone? If so, who?*
Our clinic fee schedule can be found here: www.back2health4you.com/clinic-fee-schedule/*
- I have read and agree to the clinic fees.
Clinic No-Scent Policy:*
At Back to Health Wellness Center we have a scents policy. This policy is for the health and comfort of the health care practitioners, employees and patients of Back to Health. Please avoid wearing perfumes, colognes and other personal hygiene products that have any scent. These scents can linger in the air as well as remain on the hands of the health care practitioners as many scents are not easily washed off.
- I will adhere to the no-scent policy

Is this condition interfering with your*
How would you describe the discomfort you have? (For instance is it dull, achy, deep, sharp, constant, intermittent, etc.)*
Do you feel any numbness, tingling, or pain in your arms, hands, fingers, legs or feet? If so, where:*
Have you had treatment for this new problem from other health practitioners? If so, by who and what was the treatment?*

Do you have any other problems? Where in your body and for how long? (Please list)*
Have you ever been hospitalised, had surgery, broken any bones?*
Describe:*
Have you ever had or currently have the following: Neck or back problems, headaches/migraines, concussions, osteoporosis, arthritis, joint replacements, cancer, tumors, heart problems or heart conditions, strokes, asthma, allergies, diabetes?*
Describe:*
Have you ever sprained or strained a muscle, tendon or ligament?*
Which?*
Have you ever been involved in an auto accident?*
When and describe the accident:*
Have you ever had any other personal injury or accident?*
When and describe:*

Are you currently taking any medication? If yes, what kind and dosage:*
Do you currently smoke? If yes, for how long?*
Do you currently take any vitamins, minerals, homeopathic or herbal remedies? (Please list with dosage)*

Please describe what you do during your work day. (Standing, sitting at computer, driving, lifting, hammering, etc.)*
Do you sit at a desk?*
Is your computer in front of you or off to the side?*
Is your keyboard on the desk or on a keyboard tray?*
Do you mouse left or right handed?*
Do you sit back into your chair, lean forward or a combination of both?*
Do you use a footstool for your feet?*

What is the age of your mattress?*
How would you describe your mattress?*
What is the age of your pillow?*
How would you describe your pillow?*
How do you sleep?*
Do you sleep on your*
Do you often wear heel lifts? If so, how old are they?*
Do you often wear off the shelf store bought insoles/orthotics? If so, how old are they?*
Do you often wear custom orthotics? If so, how old are they and when was the last time they were checked?*
What are your interests, hobbies, and sports you play? List as well how often, the distances/time of each sport.*

What is your Medical Doctor's name?*
What is your Medical Doctor's phone number?*
With respect to your family health history (related to you by blood), has anyone ever been diagnosed with the following? If so, whom and how are they related to you? Neck or back problems, headaches/migraines, concussions, osteoporosis, arthritis, joint replacements, cancer, tumors, heart problems or heart conditions, strokes, asthma, allergies, diabetes, and any other conditions.*