905.425.2448 ● 200 Carnwith Drive E, Unit 5 Brooklin, Ontario L1M 0A1 ● peakbrooklin.com

Reviewed by: Dr. Keber Dr. Simison

Alison Simic

Nicole Bell

Jill Moore

Stephanie McNown

confidential health history form

Dear New Patient, Please complete the following questionnaire as fully and carefully as possible. Your answers will help us to process your file, determine the nature of your complaint, and decide how best to assist you. This information will remain strictly confidential.

personal information Today’s Date:____________

_____________________________ __________________________ _____________ ____ ____ Last Name First Name D.O.B (mm/dd/yy) age M/F _______________________________________ ___________________________ ______________________ _______________ Mailing Address City Province Postal Code ____________________ ____________________ ____________________ _____________________________________________ Home Telephone Business Telephone Other (cell phone) Email Address ____________________ _______________________ _______________________________ __________________________________ Occupation Doctor’s Name Doctor’s Location & Phone # Date of Last Medical _____________________________________________________________ How were you referred to our clinic?

authorization for care of a minor (under 18 years) To be filled out by Guardian if patient is under 18 years of age.

Parent’s Name __________________________________________ Work Number ____________________________________________________

I hereby authorize and consent for Peak Health and Wellness to evaluate and care for my child

Parent / Guardian Signature______________________________________________ Date ______________________________________________

current health status

What are you seeking treatment for? ___________________________________________________________________________________________

Was this a motor vehicle accident (MVA) or a workplace injury? Yes No

How long has the condition been bothering you? _________________________________________________________________________________

Have you ever undergone advanced imaging (CT Scan, x-ray, MRI) for the condition? Yes No

If yes, when and where? ____________________________________________________________________________________________

Have you ever sought other treatment for this condition? Yes No For any other condition/ concern Yes No

Chiropractic care (Practitioner’s name)

Massage Therapy (Practitioner’s name)

Naturopathic Doctor (Practitioner’s name)

Acupuncturist (Practitioner’s name)

Physiotherapy (Practitioner’s name)

Medical Doctor (Practitioner’s name)

Other (Please specify)

What is your current general health? excellent good fair transition poor other _________________________

Are there any other conditions you would like to discuss? _____________________________________________________________________

Please list all medications and supplements you are currently taking and indicate the reason for use: ________________________________________________________________________________________________________________________

Forms last updated:

Date Initials

905.425.2448 200 Carnwith Drive E. Unit 5 Brooklin, Ontario L1M 0A1 peakbrooklin.com

confidential health history form (continued)

medical history and family history

Please indicate which of the following you are currently experiencing,

have experienced in the past, or have a family history of by writing (where applicable)

C (for current), P (for past) or F (for family history of).

cardiovascular Stroke

High Blood Pressure Circulatory Disorders Varicose Veins Pacemaker Phlebitis Heart Disease Chronic Congestive

Heart Failure Myocardial Infarction

respiratory Emphysema Asthma Chronic Cough Bronchitis Breathing Difficulty

Lung Disorder

neurological Epilepsy Multiple Sclerosis Loss of Sensation Neuritis

Other ___________ ________________ ________________

digestive & urinary Chronic Abdominal Pain Prolonged Constipation

Frequent Urination Diarrhea Irritable Bowel Syndrome Ulcerative Colitis/Crohn’s Pelvic Inflammatory Disease Gastritis Liver / Gall Bladder Kidney / Bladder

skin Easily Bruise Eczema / Psoriasis Rash Cold Sores / Warts Herpes Athlete’s Foot Loss of Sensation Skin Conditions

_______________ _______________

head and neck Headache Migraine Visual Disturbances Earaches Teeth / Jaw Pain Locked Jaw Sinus Pain Injury Dizziness / Vertigo Vision loss Hearing loss

soft tissue & joint complaints

L R

Neck

Shoulder

Arm

Chest

Abdomen

Upper Back

Mid Back

Lower Back

Hip

Leg

Knee

Ankle/Foot

Other

female Menstrual Problems Pregnant: Term __________ Menopausal Problems Endometriosis Previous C-Section Fibroids Gynecological Conditions

male Haemorrhoids Prostate Problems Sexual Dysfunction Hernias

other Diabetes Cancer HIV / AIDS Tuberculosis Hepatitis Osteoporosis Arthritis Allergies

Liver Issues lifestyle checklist Exercise regularly _______ x / week Consume Caffeine _______ x / week Consume Alcohol _______ x / week

Smoke _______ x / week

injuries Muscle Strain ________

___________________

Ligament Sprain ______

___________________

Fracture ____________

___________________

Whiplash ___________

___________________

Herniated Disc _______

___________________

Other: ______________

___________________

surgical procedures: Pins, plates, wires, artificial joints, surgical implants:

Procedure Date

Other medical conditions or concerns:

Carpal Tunnel Syndrome Insomnia Fainting Chronic Fatigue Syndrome Seasonal Affective Disorder Fibromyalgia Scoliosis Haemophilia Kidney Issues

Reviewed by: Dr. Keber Dr. Simison

Alison Simic

Ncole Bell

Jill Moore

Stephanie McNown

In the diagram provided below, please mark the areas on your body, which you feel best represent the pain(s) or sensation(s) you are experiencing. Please include all areas. Use the symbols provided below. Also, in order to complete the picture, please draw your face.

symbols: Numbness Pins & Needles

Burning Stabbing & Sharp

Dull & Aching

x x x x x x x x x xx x x x x x x x x x

+ + + + + + + + ++ + + + + + + + +

2 2 2 2 2 2 2 2 2 2 22 2 2 2 2 2 2 2 2 2 2

o o o o o o o o o o oo o o o o o o o o o o

Name Date

How long have you had pain Years Months Weeks

VISUAL PAIN ANALOG SCALE INSTRUCTIONSMake a mark (/) along the line which you think represents your current level of pain in your major area of injuiry, somewhere

between “no pain at all” and “pain as bad as it could be”

No Pain at All Pain as bad as it could be

905.425.2448 • 200 Carnwith Drive E, Unit 5 Brooklin, Ontario L1M 0A1 • peakbrooklin.com

pain diagram

Reviewed by Dr. Keber Dr. Simison Jessica Scott Alison Simic Nicole Bell Jill Moore

905-425-2448• 200 Carnwith Drive E, Unit 5 Brooklin, Ontario L1M 0A1• peakbrooklin.com

Reviewed by: □ Dr. Keber □ Dr. Simison □ Alison Simic □ Nicole Bell □ Jill Moore □ Stephanie McNown

PRIVACY CONSENT

*Includes insurance company correspondence*

I understand that in signing this document I am giving permission to Peak Health and Wellness to obtain and keep on file my personal

information that I have provided to them. I understand that the personal information provided will not be publicly published without

prior consent. The private information may include, but is not limited to:

Personal data

Personal health history

Personal treatment of data and outcome

Financial information

I understand that Peak Health and Wellness may use and disclose information in order to:

Communicate with me in a timely and effective manner

Communicate with insurance companies

Assist with my care between other health professionals

Efficiently operate a Chiropractic and Health Care Clinic

Prepare and mail documents to me, as appropriate

I understand that as a patient of Peak Health and Wellness, I have the following rights concerning my privacy:

I have the right to know why an organization or individual collects, uses or discloses my personal information

I have the right to expect an organization to handle my information reasonably and to not use it for any other purpose that

the one to which I consented

I have the right to expect an organization to protect my information from unauthorized disclosure

I have the right to ensure the identification information an organization holds about me is accurate, complete and current

I have the right to expect an organization to destroy my identification information when requested or when no longer

required for the intended original purpose (except when destruction is not allowed by law, or for insurance purposes or

allowed under the College of Chiropractors of Ontario or other governing body)

I have the right to confidentially complain to an organization about how it handles my identification information and may

escalate my complaint to the Privacy Commissioner of Canada, if need be

I have the right to remove my consent at any time by contacting Peak Health and Wellness in writing

I understand that Peak Health and Wellness will not:

Sell my information to anyone without prior consent

Share my information with organizations outside of our normal relationship that would use it to contact me, the patient

about their own products or services without prior consent (this includes audits from insurance companies).

I, the undersigned, understand and consent to this document under the Privacy Act.

Patient Name Patient Signature Date

Clinical Staff Signature

Name: __________________________________________

Date of Birth: ____/____/____

mm dd yy

E-mail Address: ___________________________________ (necessary for emailing statements)

Yes, please e-mail my chiropractic and/or naturopath statements.

Yes, please send me e-mail reminders for my appointments.

No appointment reminders needed.

Yes, I would like to receive your inspiring e-newsletter (sent twice monthly) covering a variety of health and

wellness topics.

By joining our website, you authorize us to send occasional health care related e-mails to you. Naturally, you may opt-out at any time. Please

review our complete privacy policy on our website.

MISSED/CANCELLATION POLICY

It is our desire to provide you with the best possible care and attention that we are able to offer. We kindly ask that if

you need to cancel or change your appointment to please let us know by 6pm the day before. This will allow us to

offer that time slot to another patient and get your appointment rescheduled to a more convenient time.

IMPORTANT: Our e-mail reminders are sent as a courtesy only. Please ask for an appointment card if needed or make

a note of the date and time of your appointment for your own records as you are responsible for any missed

appointments. Please note that you will receive separate emails for each appointment (i.e. one for chiropractic and one for

massage), so please be sure to open all emails to avoid missing an appointment.

**Missed/ last minute cancellations will be charged 50% of the scheduled appointment fee**

Please note that these appointments will be billed as a missed appointment and your insurance company will not

reimburse these dollars. If there are any questions, please contact the office manager at the clinic. Cancellation/missed

fees are the responsibility of the patient and must be paid in full before the next visit.

Sincerely,

Anne Kristiansen Office Manager, Peak Health and Wellness Patient Initials ______