CoordinatedInjuryRehabilitation,PainManagement,andPreventativeMedicine
Chiropractic~Physiotherapy~SportsMedicine~FamilyMedicine~Acupuncture~Massage
181510thAveSWCalgary,ABT3C0K2
P:403-270-7252F:[email protected]
WELCOMETONATIONALSPINECAREANDSPORTSMEDICINE
We look forwardtoyour firstvisit toourclinicandtheopportunity toserveyou.Wewould liketo takethis timetoreviewsomeimportantpointspriortoyourfirstappointment.
ClinicLocation181510thAvenueSWCalgary,AlbertaT3C0K2
Phone:403-270-7252Fax:403-283-6896Web:www.nationalspinecare.com
HoursofOperationMonday:7:00a.m.–8:00p.m.
Tuesday: 7:00a.m.–7:00p.m.Wednesday: 7:00a.m.–7:00p.m.Thursday: 7:00a.m.–8:00p.m.
Friday:7:00a.m.–5:00p.m.
ParkingNationalSpineCarehasparkingstallsintheparkinglotontheeastsideofourbuilding.Ourstallsaremarked–pleaselookforthesigns. Please do NOT park in any stall other than one assigned to National Spine Care as youmay be towed. Alternate parkingincludesfreehourlystreetparkingonmostoftheroadsaroundourlocation.ParkingisclearlymarkedbyCityofCalgarysignage.CancellationPolicyWerequire24hoursadvancenoticeforappointmentsshouldyouneedtocancelorrescheduleyourappointment.Theremaybeachargeforthefullamountofyourappointmentifpropernotificationisnotprovided.Youmayrequestaremindercall,textoremailpriortoyourscheduledappointment.ThisisacourtesyandnotanobligationofNationalSpineCare.Youareultimatelyresponsibleforkeepingtheappointmenttime.AppropriateDressPleasewearorbringloosecomfortableclothing,suchasT-shirt,shortsorsweat/yogapants.RegistrationPackagePleaseprintoutthenewpatientintakeformsandfillthemoutpriortoarriving.Ifyouhaven’tdonethat,pleasearrive15minutespriortoyourscheduledappointmenttoallowtimetocompletetheseforms.BillingandInsuranceInformationPaymentisexpectedatthetimeofyourvisit.WeacceptMasterCard,Visa,debit,cashandcheque.WedirectbilltoBlueCross,GreenShield,EquitableLife,TheCo-Operators,SunLife,Manulife,GreatWestLife,andothers-pleasebringyourinsuranceinformationwithyou. Patientsareresponsibleforallservicesnotcoveredbytheirhealthinsurance. Foranyotherinsuranceprovider,wearehappytoprovidedocumentationofyourtreatment,whichyoucanfilewithyourinsurancecompanyforreimbursement.AvisittooneofourmedicaldoctorsiscoveredbytheAlbertaHealthServices,butsomeoftheirtreatments,mainlyvariousinjections,arenotcovered,whichmayormaynotbecoveredthroughextendedhealthbenefits.WhattoExpectonYourFirstVisitYourinitialassessmentwilltakebetween30and45minutes(dependingonwhichhealthdisciplineyousee).Pleaseadviseusofanyrelevantimaging(MRI’s,X-rays,ultrasounds)takenwithinthelast2yearssowecanobtainthereport(s)priortoyourappointment.Apractitionerwillreviewyourmedical,healthandpainhistory,imagingreports,andperformadetailedexamination.Yourdiagnosiswillbeexplainedtoyou indetailsothatyoufullyunderstandthecauseofyour issue.Afteryourassessment, thepractitionerwillprescribeatreatmentplandesignedtomeetyourspecifichealthgoalsandneeds. Furthertestingmayberecommendedtoclarifyyourdiagnosis. If it isdetermined that the treatmentweprovide cannothelpyou, a referral to theappropriate specialistwillbemade.Withyourconsent,wecanprovideyourfamilydoctorwithaconsultationlettersummarizingthefindingsofyourassessmentandoutlininganyrecommendedtreatmentplan.Ifyouhaveanyquestions,pleasecallourclinicat403-270-7252.Welookforwardtomeetingyou!
CoordinatedInjuryRehabilitation,PainManagement,andPreventativeMedicine
Chiropractic~Physiotherapy~SportsMedicine~FamilyMedicine~Acupuncture~Massage
181510thAveSWCalgary,ABT3C0K2
P:403-270-7252F:[email protected]
PATIENTDEMOGRAPHICS
FirstName:________________________LastName:________________________PreferredName:______________________________DateofBirth:_______________________________ Gender: Male Female OtherAddress:___________________________________________________________________________________________________________________ City:________________________ Province:________________________ PostalCode:___________________________ PreferredPhone#:________________________ AlternatePhone#:____________________________________ E-mail:______________________________________ AlbertaHealthCare#:________________________________Occupation:_________________________________________ TypicalWorkingHours:_______________________________DominantHand: Left Right Height:_______________Weight:_______________ShoeSize:______________
Howdidyoufindus? Anicepersonnamed______________________________________________toldmeaboutyou. Ifoundyouonlinesearchingfor_______________________________________________________ Myfamilydoctorsentme: Yes NoFamilyDr.Name:___________________________Office#:___________________________Fax#:_________________________________
Isthisamotorvehicleaccidentinjury? Yes No Ifyes,dateofinjury:__________________________Isthisawork-related(WCB)injury? Yes No Ifyes,dateofinjury:__________________________
ExtendedHealthInsurance: _____________________________________________PolicyNumber: _____________________________________________Member/GroupNumber: _____________________________________________
Iagreethatallservicesrenderedtomearechargeddirectlytomeandthat Iampersonallyresponsible forpayment.IalsoagreethatifIsuspendorterminatemycareortreatment,anyfeesforprofessionalserviceswill be immediately due and payable. I agree that I am also responsible for any interest charged tooutstandinginvoicesgreaterthan60daysataninterestrateof18%perannum
PatientSignature: __________________________________ Date:__________________________________
WitnessSignature: __________________________________ Date:__________________________________
CoordinatedInjuryRehabilitation,PainManagement,andPreventativeMedicine
Chiropractic~Physiotherapy~SportsMedicine~FamilyMedicine~Acupuncture~Massage
Yourstoryisimportant.Whatyoufeel,howitstarted,andanypatternsyouhavenoticedwillhelp
usunderstandwhyyouhaveyourissues.
Whereareyouhavingyourissues?
Isthisa: NewIssue RecurringIssueWhendiditstart?Howdiditstart?What does your pain (health issue) currentlylimityoudoing?What activitieswould you love to get back to ifwecanhelpyougetoutofpain?For you current pain/health issue whattreatmentshaveyoutriedalready?Physiotherapy ChiropracticMassage AcupunctureMedications Other______________________
Practitioners’NotesHere:
CoordinatedInjuryRehabilitation,PainManagement,andPreventativeMedicine
Chiropractic~Physiotherapy~SportsMedicine~FamilyMedicine~Acupuncture~Massage
Ifyourissueisoneofneckorbackpain,pleaseanswerthefollowingquestions:Thinkingaboutthelast2weekstickyourresponsetothefollowingquestions:
1. Mybackpainhasspreaddownmyleg(s)/arm(s)atsometimeinthelast2weeks Disagree(0) Agree(1)
2. Ihavehadpainintheshoulderorneckatsometimeinthelast2weeks Disagree(0) Agree(1)
3. Ihaveonlywalkedshortdistancesbecauseofmybackpain Disagree(0) Agree(1)
4. Inthelast2weeks,Ihavedressedmoreslowlythanusualbecauseofneck/backpain Disagree(0) Agree(1)
5. It’snotreallysafeforapersonwithaconditionlikeminetobephysicallyactive Disagree(0) Agree(1)
6. Worryingthoughtshavebeengoingthroughmymindalotofthetime Disagree(0) Agree(1)
7. Ifeelthatmyneck/backpainisterribleandit’snevergoingtogetanybetter Disagree(0) Agree(1)
8. IngeneralIhavenotenjoyedallthethingsIusedtoenjoy Disagree(0) Agree(1)
9. Overall,howbothersomehasyourneck/backpainbeeninthelast2weeks?
Notatall(0) Slightly(0) Moderately(0) Verymuch(1) Extremely(1)
Practitioners’NotesHere:Totalscore(all9):__________________SubScore(Q5-9):___________
CoordinatedInjuryRehabilitation,PainManagement,andPreventativeMedicine
Chiropractic~Physiotherapy~SportsMedicine~FamilyMedicine~Acupuncture~Massage
Circleanyconditionsthatarepresentlycausingyouaproblem.Underlinethosethathavecausedyouproblemsinthepast.
GENERALSYMPTOMS RESPIRATORY GENITOURINARY
FeverSweatsFaintingSleepdisturbanceFatigueNervousnessWeightlossWeightgain
ChroniccoughSpittingupphlegmSpittingupbloodChestpainWheezingDifficultybreathingAsthma
FrequenturinationPainfulurinationBloodinurinePusinurineKidneyinfectionProstatetroubleUncontrollableurineflow
NEUROLOGICAL CARDIOVASCULAR GASTROINTESTINAL
VisualdisturbanceDizzinessFaintingConvulsionsHeadacheNumbnessNeuralgia(nervepain)PoorcoordinationWeakness
RapidbeatingheartSlowbeatingheartHighbloodpressureLowbloodpressurePainoverheartHardeningofarteriesSwollenanklesPoorcirculationPalpitationsColdhandorfeetVaricoseveins
PoorappetiteDifficultdigestionHeartburnUlcersNauseaVomitingConstipationDiarrheaBloodinstoolGallbladder/jaundiceColitis
EYES,EARS,NOSE,THROAT
MUSCLE&JOINT FORWOMENONLY
EyepainDoublevisionRinginginearsDeafnessNosebleedsTroubleswallowingHoarsenessSinusinfectionNasaldrainageEnlargedglands
NeckpainLowbackpainArmpainShoulderpainLegpainKneepainFootpainPain/numbnessdownarmsorlegsPainbetweenshouldersswollenjointsSpinalcurvatureArthritisFractures
PainfulmenstruationHotflashesIrregularcycleCrampsorbackpainVaginaldischargeNippledischargeLumpsinbreastMenopausalsymptomsBirthcontrolpillsMiscarriagesComplicationswithpregnancyPregnant?Y/NWeek?Other:
CoordinatedInjuryRehabilitation,PainManagement,andPreventativeMedicine
Chiropractic~Physiotherapy~SportsMedicine~FamilyMedicine~Acupuncture~Massage
181510thAveSWCalgary,ABT3C0K2
P:403-270-7252F:[email protected]
CONSENTTOTHECOLLECTION,USE,ANDDISCLOSUREOFPERSONALINFORMATION
Pleasenotethataphotocopyofthisconsentformwillhavethesameauthorityastheoriginal.Theoriginalformisnottoberemovedfromtheclient’sfileatNationalSpineCareandSportsMedicine(NSCSM).I, _________________________________, consent to the collection, use anddisclosure ofmypersonal information for the purpose ofproviding services to me as they relate to my injury, illness, treatment and/ormy claim for compensation of benefits. Inaddition,NSCSMmay collect, use or disclosemy personal information if otherwise permitted or required by law to do so.Personalinformationincludesanyinformationaboutmeotherthaninformationthatisotherwisepubliclyavailable.NSCSMisamultidisciplinaryandcollaborativehealthcareclinicwithcentralizedpatients’charts.Assuch, thepatientchartinformation,initsentirety,maybesharedamongallhealthpractitionersworkingfortheNSCSM.I understand, and agree, that personal information may also be used or disclosed to obtain payment for the services,determine any entitlement to insurance or other benefits, identify treatment outcomes, and the extent of services in thisinformationmaybeprovidedtoNationalSpineCare,andreferralsources.NationalSpineCaremayalsocompileanonymizedinformation,notpersonalinformation,toprovideaggregatestatisticforinsuranceorgovernmentagencieswhenrequestedtodosoorforqualityinitiativesandclinicalresearch.I, ____________________________________ hereby authorize (please check all applicable boxes) any authorized representative ofNSCSMto:Send copies (by email,mail, or fax) or give a verbal report ofmyassessment, treatmentplan, interimprogress reports,
dischargeplan,andfollowupreportsasapplicabletotheindividual(s)/organization(s)namedbelow:Doctor:_______________________________________________________
InsuranceCompany/NameofAdjustor:__________________
Employer/NameofContact:_______________________________
Lawyer/PersonalRepresentative:________________________
WCB/CaseManager:_______________________________________
Otherindividualtobenamed:____________________________
Contact any of the individuals/organizations namesmentionedaboveforthepurposeofcollectinginformationregardingmy injury, impairment, disability, functional orvocationalneeds.Contactmycurrentorpreviousemployertodiscussthe
physical demands of my regular employment, theavailability of modified or transitional work, and toestablishareturntoworkplanasapplicable.
Contact____________________________________________________forreimbursementpurposesonly.
Ihavereadtheaboveauthorizationandindicatemyconsentbymysignature.Theauthorizationshallbevalidfor12monthsfromthisdateoruntil_______________________________(dd/mm/yyyy).Inaddition,IconsenttothedisclosureofmypersonalinformationbyNationalSpineCareandSportsMedicinetoathirdpartywiththepotentialoractualsale,reorganization,consolidation,mergeroramalgamationofNationalspineCareandSportsMedicine.MyconsentfordisclosureofmypersonalinformationisinthesecircumstancesvalidunlessIrevokeitonwrittennoticetoNationalSpineCareandSportsMedicine.______________________________________________________________ ______________________________________________________________Signatureofclient(ordulyauthorizedrepresentative Date(mm/dd/yyyy)______________________________________________________________ ______________________________________________________________SignatureofWitness Date(mm/dd/yyyy)
