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Step 1 of 18 - Personal Information

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  • 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!
  • 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.
  • 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

  • Children Information

  • Please enter a number from 0 to 20.
  • Emergency Contact Information
  • (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.
  • 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
  • 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.
  • 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
  • Health Information

    (Please answer each question and if yes is answered please explain)
  • CURRENT PROBLEM

  • Doctor of Chiropractic’s information

  • Date Format: DD dash MM dash YYYY
  • Registered Massage Therapist’s information

  • Date Format: MM slash DD slash YYYY
  • Other Notable Conditions

  • PAST MEDICAL HISTORY (BIRTH TO PRESENT)

  • GENERAL HEALTH QUESTIONS

  • (please name Brand / Supplement Type / Dosage)
  • WORK QUESTIONS

  • (standing, sitting at computer, driving, lifting, hammering, etc)
  • DAILY ACTIVITY QUESTIONS

  • 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
  • Date Format: MM slash DD slash YYYY
  • Diet And Lifestyle

  • Many of the following questions are for our naturopath’s required information
  • Check all that apply.
  • Please describe what you typically eat in one day:

  • FEMALE REPRODUCTIVE SYSTEM

  • Date Format: MM slash DD slash YYYY
  • Have you been diagnosed with, or have you ever experienced any of the following?
  • Please check all of the symptoms that apply to you.
  • Please check all symptoms that apply to you.
  • Please check all symptoms that apply to you.
  • Please check all that apply to you.
  • Please check all symptoms that apply to you.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • 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.
  • If you answer yes to any of the below questions please list the family members and which side of the family it is.
  • This field is for validation purposes and should be left unchanged.

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Our Location

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240 Catherine St #100
Ottawa,
ON
K2P 2G8

(613) 237-3306

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  • Our Clinic
    • Patients
      • Visiting the Centre
      • Clinic Fee Schedule
      • Do I Need a Referral?
      • Book an Appointment
      • Patient Forms
      • Your Report of Findings
    • Photos and Videos
      • Videos
    • Careers – Join our Team!
  • Services
    • Chiropractic
      • Active Release Technique
      • Acupuncture
      • Cranial Therapy
      • Naturopathic Care
    • Physiotherapy
    • Orthotics Ottawa
    • Gait Analysis for Better Foot Health
    • Massage Therapy
    • Additional Services and Articles
    • What We Treat
  • Products & Supplements
  • Patient Stories