#205 4401 Albert Street, Regina1 (306) 721-2221

Consultation Form

If you would prefer to print this form and fill it out by hand, click here.
(Note: The information you provide us will only be seen by our office.)

1. First name:
2. Middle initial:
3. Last name:
4. Date of birth:
5. Address:
6. City:
7. Province:
8. Postal code:
9. Phone number (home):
10. Phone number (work):
11. Phone number (cell):
12. E-mail address:
13. Occupation:
14. Emergency contact:
15. Emergency contact phone number:
16. Family physician:
17. Date of last physical:
 
18. What is your reason for consulting us today?
19. How long have you had this condition?
20. What started this condition?
21. Did this start at work? Yes No
22. Was this caused by an auto accident? Yes No
23. Please indicate the one spot where your pain is the worst (click image):
24. How would you describe the pain?
25. Please indicate how painful it is on the following line: (5)
No Pain
Worst Pain Ever
26. What makes the pain worse?
27. What makes the pain better?
28. Is the pain getting worse? Yes No
29. Is the condition affecting your:
Sleep
Work
Daily routine
30. What is your weight?
31. What is your height?
32. What are your interests/hobbies?
33. Please check any medications that you are currently taking:
Birth control
Insulin
Blood pressure pills
Anti-inflammatories
Muscle relaxants
Anti-depressants
Blood thinners
Vitamins/supplements
34. Please list any surgical procedure(s) and the year performed:
35. Please check the medical conditions that you and/or a blood relative have had:
Cancer
High blood pressure
Stroke
Heart attack
Diabetes
Asthma
Allergies
Arthritis
Osteoporosis
Multiple Sclerosis
Epilepsy
Dizziness
Fainting
Research

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