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Step 1 of 18 - Personal Information
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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?
*
Yes
No
Who?
*
Age
*
Date of Birth
*
Month
1
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Day
1
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Year
2022
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1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Sex
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Male
Female
N/A
Gender
*
How did you find out about our clinic?
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Address
*
Street Address
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
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
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Phone# - Work
Occupation
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Status
*
Single
Partnered
Married
Divorced
Widowed
Children Information
Number of Children
*
Please enter a number from
0
to
20
.
Ages of children
*
Under 18
18-24
25-34
35-44
45-54
55-64
65 or Above
Prefer Not to Answer
Do you have extended health benefits?
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Yes
No
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
Health Information
(Please answer each question and if yes is answered please explain)
CURRENT PROBLEM
What is your main health concern/condition?
*
How long have you had this condition?
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Less than a month
1-6 months
1-3 years
Over 3 Years
Have you had this or a similar condition in the past?
*
Yes
No
When did you have this condition?
*
What do you do to relieve your symptoms?
*
What worsens your symptoms?
*
Did the condition occur as a result of a particular incident?
*
Yes
No
What was the incident that caused your condition?
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Is this condition getting progressively worse?
*
Yes
No
Is this condition interfering with your :
*
None
Work
Sleep
Daily Routine
Sitting
Exercising
Standing
Others
Please Specify
*
Provide further details on how your condition interferes with the above selections:
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How would you describe the discomfort you have? For instance is it dull, achy, deep, sharp, constant, or intermittent.
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Do you feel any numbness, tingling, or pain into your arms, hands, fingers, legs or feet or toes?
*
Yes
No
Where do you feel numbness, pain or tingling?
*
not applicable
arm(s)
hand(s)
fingers
leg(s)
feet/foot
others
Please Specify
*
Has an x-ray / MRI / CT scan / Bone scan been performed?
*
Yes
No
Procedure
*
Not Applicable
x-ray
MRI
CT scan
Bone scan
Others
Please indicate what body part and the year:
*
Have you been diagnosed with osteoporosis or osteopenia?
*
Yes
No
Describe the severity of the osteoporosis or osteopenia:
*
Have you had treatment for this problem from other health practitioners?
*
Yes
No
Practitioners Name
*
First
Last
Describe the type of treatment you received:
*
Have you ever had massage therapy before?
*
Yes
No
Have you received chiropractic treatment in the past?
*
Yes
No
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?
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Yes
No
Please list the condition(s) and how long you have had them.
*
How long has it been since you really felt good?
*
PAST MEDICAL HISTORY (BIRTH TO PRESENT)
Have you ever had surgery?
*
Yes
No
Please list any surgical operations and the years they were performed.
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Have you ever broken or fractured any bones?
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Yes
No
Which ones and when?
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Have you ever sprained or strained a muscle or ligament?
*
Yes
No
Which ones and when?
*
Have you ever been involved in an auto accident(s)?
*
Yes
No
When? Please describe the accident
*
Have you had any other personal injury or accident?
*
Yes
No
Please describe the accident
*
GENERAL HEALTH QUESTIONS
Are you currently taking any medication?
*
Yes
No
List Type/Dosage
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Do you smoke or have you ever smoked?
*
Yes
No
How many years? and how much per day?
*
Do you currently take any vitamins, minerals, homeopathic or herbal remedies?
*
Yes
No
(please name Brand / Supplement Type / Dosage)
Brand
*
Supplement Type
*
Dosage
*
Do you have any internal pins, wires, artificial joints or other special equipment (such as a pacemaker or hearing aid)?
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Yes
No
Please explain
*
Shoe size
*
shoe Width
*
Narrow
Wide
Regular
shoe Sizing
*
Men's
Women's
Height (ft.)
*
Weight (lbs)
*
Can you walk a kilometer comfortably?
*
Yes
No
Do your feet hurt when you get out of bed?
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Yes
No
Are your legs/knees/ or feet sore by the end of day?
*
Yes
No
After walking long distances/or running do your shins hurt?
*
Yes
No
Do you suffer from Rheumatoid arthritis or Osteoarthritis in your feet?
*
Yes
No
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?
*
Yes
No
If at a desk, is your monitor placed
*
In Front of you
Off to the side
Do you use multiple monitors?
*
Yes
No
Is your keyboard
*
On the desk
In a keyboard tray
How do you use your mouse?
*
Left handed
Right handed
How do you sit in your chair?
*
Sit back in your chair
Leaned forward in your chair
Combination of both
Do you make use of a footstool for your feet
*
Yes
No
Do you have a sit/stand situation at work?
*
Yes
No
DAILY ACTIVITY QUESTIONS
What is the age of your mattress?
*
Less than a month
1-6 months
1-3 years
Over 3 Years
Would you describe it as
*
Soft
Medium
Firm
What is the age of your pillow?
*
Less than a month
1-6 months
1-3 years
Over 3 Years
Never used
Is your pillow
*
Flat
Contoured
How do you sleep?
*
Right side
Left side
Stomach
Back
Do you often wear heel lifts, off the shelf insoles/orthotics or custom orthotics?
*
Yes
No
Please specify the type of heel or lift?
*
Lifts
Custom orthotics
Off the shelf insoles
Orthotics
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
Diet And Lifestyle
Many of the following questions are for our naturopath’s required information
Do you eat or use any of the following?
*
Not Applicable
Aluminum pans
Plastic tupperware
Microwave
Air fresheners
Fried foods
Fast foods
Refined/processed food
Candy
Artificial sweeteners
Luncheon meats
Margarine
Scented body products
Others
Please Specify
*
Do you have any dietary restrictions? (Vegetarian, religious, etc.)
*
Yes
No
What dietary restrictions do you have?
*
On average, how do you eat your meals?
*
Check all that apply.
Not Applicable
With family around the table
In front of the TV
On the run
Restaurant
Fast food
Others
Please Specify
*
How often do you eat at a restaurant?
*
not applicable
never
rarely
sometimes
often
always
others
Untitled
*
How often do you eat fast food?
*
not applicable
never
rarely
sometimes
often
always
others
Please Specify
*
Please describe what you typically eat in one day:
Breakfast
*
Lunch
*
Dinner
*
Snacks
*
Food Likes and Cravings
*
Water (cups per day)
*
Milk (cups per day)
*
Coffee (cups per day)
*
Tea (cups per day)
*
Alcohol (cups per day)
*
Other
Do you have a bowel movement daily?
*
Yes
No
How stressful is your work, or other areas of your life?
*
High
Moderate
Low
How well do you feel you handle these stresses?
*
How many hours do you sleep daily?
*
Do you have problems with sleeping?
*
Yes
No
Explain your trouble sleeping.
*
Do you wake feeling rested?
*
Yes
No
Sometimes
FEMALE REPRODUCTIVE SYSTEM
Are you possibly pregnant?
*
No
Yes
Expected due date
*
Date Format: MM slash DD slash YYYY
Describe your menstrual cycle
*
Regular
Irregular
Menopausal
Peri-menopausal
PMS Symptoms
Do you take birth control?
*
Yes
No
Birth Control Method? (Pill, Injection, Nuvaring, Other)
*
Have you been diagnosed with, or have you ever experienced any of the following?
Circulatory/Respiratory
*
Not Applicable
Chronic congestive heart failure
Heart disease
Another heart condition
High blood pressure
Low blood pressure
Varicose veins
Phlebitis
Deep vein thrombosis
Buerger’s disease
Chronic cough
Bronchitis
Asthma
Emphysema
Shortness of breath
Raynaud’s disease/phenomenon
Others
Please Specify
*
Nervous system
*
Not Applicable
Ellepsy
Multiple sclerosis
Cerebral palsy
Parkinson’s
Nerve lesion
Sciatica
Carpal tunnel syndrome
Others
Please Specify
*
Musculoskeletal
*
Not Applicable
Scoliosis
Bone or joint disease
Arthritis
Joint instability
Tendinitis
Fractured bones
Jaw pain (TMJ)
Whiplash
Concussion
Others
Cognitive Symptoms of a Concussion
*
Please check all of the symptoms that apply to you.
Difficulty thinking clearly
Difficulty concentrating
Difficulty remembering new information
Disorientation
Temporary amnesia
Short term memory problems
Poor judgement
Slow thinking
Difficulty reading
Difficulty with math
Poor word recall
Forgetting people’s names
Poor decision making
Lack of organization
Longer response time
Confusion
Brain fog
Forgetting previously learned skills
Difficulty driving
Get lost easily
Spelling difficulty
Poor comprehension
Difficulty following instructions
Difficult to think in noisy environments
Inability to multitask
Poor follow through
Difficulty with logic
Difficulty with abstract thinking and being creative
Difficult to watch TV, use the computer or play video games
Loss of consciousness
Slurred speech
Absence seizures
Chills
Difficulty staying focused
N/A
Sleep Symptoms of a Concussion
*
Please check all symptoms that apply to you.
Sleeping more than usual
Sleeping less than usual
Trouble falling asleep or staying asleep
N/A
Physical Symptoms of a Concussion
*
Please check all symptoms that apply to you.
Headache
Migraine
Tension headaches
Fuzzy or blurry vision
Double vision
Feeling groggy
Nausea or vomiting
Dizziness or lightheadedness
Sensitivity to noise, light or touch
Balance problems
Fatigue
Feeling tired
Having no energy
TMJ issues
Hearing problems
Tinnitus
Loss of libido
Exaggerated awareness of aches and pains
Loss of balance
Sense of smell or taste change
Difficulty in swallowing
Slowed reflexes
Gait changes
Changes in co-ordination or speed of performance
Seizures
Pressure in the head
Neck pain
Strange taste in mouth
Seeing stars
N/A
Behavioural Symptoms of a Concussion
*
Please check all that apply to you.
Confrontational
Temper tantrums
Fearfulness
Impatience
Thoughtlessness
Compulsive behaviors
Obsessive behaviors
Lack of social ease
Personality changes
Bi-polar
Difficulty adapting to change
N/A
Emotional/Mood Symptoms of a Concussion
*
Please check all symptoms that apply to you.
Irritability
Sadness
More emotional
Nervousness or anxiety
Depressed
Agitation
Apathy
Anxiety
Feeling of going crazy
Frustration
Anger
Hostility
Paranoia
Guilt
Shame
Helplessness
Why me
Mood swings
Low motivation
Gullibility
Easily overwhelmed
Exaggerated response to stimuli
Low self-esteem
Nightmares
Day terrors
Mania
Excessive excitement
N/A
Please Specify
*
Skin
*
Not Applicable
Irritated skin conditions
Contagious conditions
Frostbite
Lack of sensation
Sensitivities to oils, lotions, detergents
Other allergies or hypersensitivities
Others
Please Specify
*
General
*
Not Applicable
Cancer/Tumors
Undiagnosed lump
Diabetes
Kidney problems
Liver problems
Eating disorder
Recent abortion or vaginal birth
Loss of vision or hearing
Drug/Alcohol addiction or withdrawal
Infectious conditions (hepatitis, HIV, etc.)
Others
Please Specify
*
Do you have any Allergies/Sensitivities?
*
Yes
No
If you have Allergies/Sensitivities (environmental, foods, pets, drugs, etc.) please list them here:
*
Have you received all childhood vaccinations?
*
Yes
No
Do you get regular flu vaccinations?
*
Yes
No
Have you had any complications from any vaccinations?
*
Yes
No
Please explain the complications.
*
Date of last Blood Test
*
Date Format: MM slash DD slash YYYY
Have you taken antibiotics before?
*
yes
no
Date for last Antibiotic Use
*
Date Format: MM slash DD slash YYYY
Reason for last Antibiotic Use
*
Have you had a heart attack?
*
Yes
No
If yes, When?
*
Have you ever suffered from a stroke?
*
Yes
No
If yes, When?
*
Please list any other condition not listed & provide details as necessary
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?
*
Yes
No
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?
*
Yes
No
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.
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