welcome to national spine care and sports medicine...chiropractic ~ physiotherapy ~ sports medicine...

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!





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:__________________________________



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:



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):___________



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:





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)

welcome to national spine care and sports medicine...chiropractic ~ physiotherapy ~ sports medicine...

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