New Patient Paperwork - Back to Health Wellness Centre

DISCLAIMER*
This form takes approximately 30 minutes to complete. Please ensure that when you have the time to do so, you take the time to read and answer every question; including as many details as possible. THIS IS DONE FOR YOUR OWN SAFETY as our clinic assesses every patient according to their individual needs and uses different techniques and tools to do so!
- I have read and agree with the disclaimer
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.
As a patient of Back to Health do you understand our scent policy and can we ask that you adhere to it?*
- Yes
When attending your first appointment at the Back to Health Wellness Centre, please bring the following items: Shorts, a T-shirt, running shoes(older pair with use), your orthotics (if you have some), and any medical reports you may have.
If the question dosen't apply to you, Please enter N/A
Patient Information
Name of Patient*
First Last
Were you referred by anyone?*
Who?*
Age*
Date of Birth*
Sex*
Gender*
How did you find out about our clinic?*
Address*
Street Address City Province Postal Code
Email*
Email Communication*
- I consent to receive electronic communication messages from Back to Health & Wellness Centre.
- I do not consent to receive electronic communication messages from Back to Health & Wellness Centre
Phone# - Home or Cell*
Phone# - Work
Occupation*
Status*
Children Information
Number of Children*
Please enter a number from 0 to 20.
Ages of children*

Do you have extended health benefits?*
With which company have you extended health benefits?*

Emergency Contact Information
Name*
First Last
Relation*
Phone*
Email*
Other Health Care Providers*
(Please list)
If you would like us to release information, appointment times, account information to your partner and/or family members please give us written permission below. We require your written permission with respect to this. Your privacy is very important to us. If you would like to review the contents of our privacy policy, please ask at our front reception.
Authorized family member’s names (Please list)*

Chiropractic Biomechanical Exam
Day 1: Exam - 45 minutes
We will perform a comprehensive exam to check joint movement, muscle function, range of motion to identify specific problem areas. This is a muscle, skeletal, biomechanical, neurological exam. The first part of the exam will be performed by Keri-Lyn our Kinesiologist. Part of this may include a foot scan/gait analysis using computer technology. This can identify any problems relating to your feet which may relate to the biomechanics of your body. Then Dr. Barbara Rodwin will complete the exam. Please arrive 5 minutes early for your exam. We have specific time slots allotted for exams. If you are late, we may have to re-schedule your appointment, or Dr. Rodwin will only be able to perform a portion of your exam.
Day 2: Report of Findings - 45 minutes-1 hr
Dr. Barbara Rodwin and Keri-Lyn will be reviewing your exam findings. They will prepare a written report detailing the results. Keri-Lyn will be reviewing this with you. Any recommendations will be made to aid in treating your condition. After Keri-Lyn has reviewed this you will be seeing Dr. Barbara Rodwin for treatment.
Clinic Fees
Please click this link for complete information on our rates and fees
*
- I have read and agree to the clinic fees
Sharing Information
The health care practitioners at Back to Health Wellness Centre prefer to work together as a team in order to aid you in improving your overall health, function and problem. We ask that you allow us to share information regarding your current health status with the other practitioners you see. We find that patients improve quicker with this open line of communication. If at any time you would prefer that we not share this information please discuss this with your health care provider at the clinic.

Cancellation Policy
Our policy at Back to Health Wellness Centre is that we ask for at least 12 hours notice to cancel an appointment. Time is important to all of us. If you can’t make it to an appointment, it is quite likely someone else could benefit from your slot.
You will be charged for a missed appointment if you do not show up for an appointment. If less than 12 hours’ notice is given, we reserve the right to charge you the fee of the appointment that you originally scheduled.
Please be aware that private health care insurance plans do not cover the fee for missed appointments.
Thank you for your understanding.
Confirm Review of Intake Process
I have read and reviewed the intake process (initial consultation, examination, and report of findings) and sharing of health information between health care practitioners. I have also reviewed the fee schedule for massage services, chiropractic services, acupuncture and the Active Release Technique and the cancellation policy at Back to Health. If I have any questions regarding the initial intake process, I will discuss these with Dr. Rodwin and any questions regarding the fees, I will discuss these with the front desk staff.
Please type your name to acknowledge you understand our process*
IF YOU ARE UNDER 18 YEARS OF AGE, A PARENT OR GUARDIAN MUST COMPLETE THIS PART.
I consent to have my son/daughter/ward, treated by Dr. Barbara Rodwin and/or a registered massage therapist on this date and on subsequent visits
Enter your name to consent to above statement

Doctor of Chiropractic’s information
Name*
First Last
Last Treatment Date*
Date Format: DD dash MM dash YYYY
Address*
Street Address City State / Province / Region ZIP / Postal Code
what you were treated for?*

Registered Massage Therapist’s information
Name*
First Last
Last Treatment Date*
Date Format: MM slash DD slash YYYY
Address*
Street Address City State / Province / Region ZIP / Postal Code
what you were treated for?*

Other Notable Conditions
Do you have any other conditions we should be made aware of?*
- Yes
- No
Please list the condition(s) and how long you have had them.*
How long has it been since you really felt good?*

WORK QUESTIONS
Please describe what you do during your work day.*
(standing, sitting at computer, driving, lifting, hammering, etc)
Do you work in an office?*
If at a desk, is your monitor placed*
Do you use multiple monitors?*
Is your keyboard*
How do you use your mouse?*
How do you sit in your chair?*
Do you make use of a footstool for your feet*
Do you have a sit/stand situation at work?*
- Yes
- No
DAILY ACTIVITY QUESTIONS
What is the age of your mattress?*
Would you describe it as*
What is the age of your pillow?*
Is your pillow*
How do you sleep?*
Do you often wear heel lifts, off the shelf insoles/orthotics or custom orthotics?*
Please specify the type of heel or lift?*
How old are they?*
When is the last time they were checked?*
What are your interests and hobbies?*
Please list them above and as well how often, the distances or time of each sport or hobby

Please, provide your medical doctor's information.
Please provide your Medical Doctor’s information
Name*
First Last
Phone*
Address*
Street Address City ZIP / Postal Code
Your last physical*
Date Format: MM slash DD slash YYYY

FEMALE REPRODUCTIVE SYSTEM
Are you possibly pregnant?*
Expected due date*
Date Format: MM slash DD slash YYYY
Describe your menstrual cycle*
PMS Symptoms
Do you take birth control?*
Birth Control Method? (Pill, Injection, Nuvaring, Other)*

FAMILY MEDICAL HEALTH INFORMATION
Many health problems are the result of hereditary conditions. This information about your immediate family will give us a better picture of your total health. Please try to think of the health history of your parents, siblings, grandparents, aunts and uncles, related to you by blood and not by marriage.
Do you know the health history of your family?*
If you answer yes to any of the below questions please list the family members and which side of the family it is.
Neck or back problems? If yes, whom, and how are they related to you?*
Headaches/Migraines? If yes, whom, and how are they related to you?*
Osteoporosis? If yes, whom, and how are they related to you?*
Arthritis? If yes, whom, and how are they related to you?*
Joint replacements? If yes, whom, and how are they related to you?*
Cancer? If so, whom, and how are they related to you?*
Tumors? If so, whom, and how are they related to you?*
Heart problems/conditions? If so, whom, and how are they related to you?*
Strokes? If so, whom, and how are they related to you?*
Asthma? If so, whom, and how are they related to you?*
Allergies? If so, whom, and how are they related to you?*
Diabetes? If so, whom, and how are they related to you?*
Depression? If so, whom, and how are they related to you?*
Mental Illness? If so, whom, and how are they related to you?*
Can you think of any other things that run in your family?*
If so, please describe. (what, whom, and how are they related to you?)*
If you see any of the health care professionals at Back to Health Wellness Centre, do you give permission for your health care providers to share to discuss your condition?*
- Yes
- No
Phone
This field is for validation purposes and should be left unchanged.

Step 1 of 18 - Personal Information

Patient Information

Children Information

Chiropractic Biomechanical Exam

Day 1: Exam - 45 minutes

Day 2: Report of Findings - 45 minutes-1 hr

Clinic Fees

Sharing Information

Cancellation Policy

Confirm Review of Intake Process

IF YOU ARE UNDER 18 YEARS OF AGE, A PARENT OR GUARDIAN MUST COMPLETE THIS PART.

Health Information

CURRENT PROBLEM

Doctor of Chiropractic’s information

Registered Massage Therapist’s information

Other Notable Conditions

PAST MEDICAL HISTORY (BIRTH TO PRESENT)

GENERAL HEALTH QUESTIONS

WORK QUESTIONS

DAILY ACTIVITY QUESTIONS

Please, provide your medical doctor's information.

Diet And Lifestyle

Please describe what you typically eat in one day:

FEMALE REPRODUCTIVE SYSTEM

FAMILY MEDICAL HEALTH INFORMATION

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