New Patient Form | Osteopathycanada

PATIENT INFORMATION

First Name:

Birthday:

City:

Province:

Home #:

Email:

Referral Source:

Phone:

Surgeries:

When did your symptoms begin?

Last Name:

Address:

Postal Code:

Work #:

Mobile:

Occupation:

Family Doctor:

Have you ever been in any accidents? YES / NO. Date of Accident:

Major Complaints:

Current Medications:

Below are a list of diseases which may seem unrelated to the purpose of your appointment. However, these questions must be answered carefully as these problems can affect your overall course of care.

CHECK ANY OF THE FOLLOWING DISEASES YOU HAVE HAD:

PneumoniaRheumatismPolioTuberculosisWhooping CoughPleurisySmall PoxDiabetesCancerHeart DiseaseThyroidGoutArthritisEpilepsyMental DisorderEczemaAnemiaOther

HEALTH HABITS:

Atcohol (>2 drinks per week)Cigarettes

Do You Exercise Regularly?

YesNo

How would you rate your nutrition?

ExcellentFairPoor

Have you been tested HIV positive?

YesNo

CHECK ANY OF THE FOLLOWING YOU HAVE HAD:

MUSCULO-SKELETAL CODE

Low Back PainPain between ShouldersNeck PainShoulder PainArm PainMid back PainJoint Pain/StiffnessWalking ProblemsDifficult Chewing/Clicking JawGeneral StiffnessMuscle Twitching/SpasmsSwollen jointsPain Legs/FeetSciatica

Nervous System Code

NervousLoss of BalanceNumbnessDizzinessForgetfulness (Memory/Concentration)DepressionConvulsionsNumber/Tingling ExtremitiesStressFatigue/Low EnergyAllergies/Hay feverLoss of Sleep / Sleep troubleFeverHeadachesInner Tension/StressIrritability

GASTRO-INTESTINAL CODE

Poor/Excessive ApetiteExcessive ThirstFrequent NauseaVommiting / DiarrheaConstipationHemorrhoidsLiver ProblemGall Bladder ProblemsWeight TroubleAbdominal CrampsIndigestionGas/Bloating after MealsHeartburnBlack/Bloody StoolColitisUlcers

GENITO-URINARY CODE

Bladder TroublePainful/Excessive UrinationDiscolored UrineKidney Trouble

CARDIO-VASCULAR CODE

Chest PainShortness of BreathHigh Blood PressureHigh CholesterolIrregular HeartbeatHeart ProblemsLung Problems/CongestionVaricose VeinsAnkle SwellingStrokeAsthma

EENT CODE

Vision ProblemDental ProblemsSore ThroatEar AcheHearing DifficultSinus TroubleLoss of SmellLoss of TasteRinging in ears

MALES ONLY CODE

ProstateSexual Dysfunction

FAMILY HISTORY

The following members have the same or similar problem as I do:

MotherFatherBrotherSisterSpouseChild

FEMALES ONLY

Menstrual IrregularityMenstrual CrampsVaginal Pain/InfectionBreast Pain/LumpsOther

When was your last period?

Are you pregnant?

YesNoNot Sure

Consent To Treatment

The Ontario Government prefers the patient to give consent to treatment in writing. By signing this Consent Form you acknowledge that you consent to treatment and have had your questions about treatment answered to your satisfaction.

Osteopathy, Physiotherapy, Massage, to name the few treatments we provide may include manual therapies where the health practitioner places his or her hands on your body such as your anterior chest wall, pelvis floor and pubic bones. We may ask you to remove some of your clothing and will drape you appropriately to facilitate treatment. You need to be aware that many treatment techniques may involve some contact between your body and the health practitioner’s body. For certain osteopathic internal treatments, we may have to work in your mouth. In this case, a disposable vinyl glove will be worn.

We, as a team, are committed to providing an excellent quality of treatment and hospitality to our patients. If you do not feel comfortable with a given technique, please tell your practitioner immediately. The technique will be discontinued or modified so it is comfortable for you.

Privacy Policy

On January 1, 2004, the Personal Information Protection and Electronic Documents Act (the Act) came into effect with a mandate to balance the privacy rights of the individual and the needs of commercial organizations to collect information for business purposes.

Classical Osteopathy remains committed to you and your health as well as respects your right to confidentiality. The privacy policy of Classical Osteopathy (CO) is founded on the following principles:

Accountability

CO is responsible for maintaining and protecting all information collected by the clinic.

Limited and Accurate Collection of Information

CO limits the collection of personal information to only that which is necessary for the provision of excellent health care. This information is accurately maintained in its most current form in order to fulfill the purposes for which it was collected.

Consent

A decision to receive care at CO implies consent for the sharing of information internally, for purposes related to your health care only. Written consent is required from you in order to share your health care information externally. You may withdraw this consent in writing at any time.

Disclosure and Retention

Patient information is kept in a secure manner for a period of 10 years. This information will only be utilized for the purposes for which it was collected or if required by law.

Information Storage

Appropriate security measures are utilized to secure the privacy of all information collected in the delivery of your health care services.

Patient Access

You are entitled to view the information collected by CO regarding your care. You may obtain a copy of your records. There is a fee for this service.

By signing this form, I hereby give consent to therpist for treatment and also to the collection, use, maintenance and disclosure of my personal information as indicated above, unless and until I advise otherwise in writing.

Signature

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