Date

________________

Welcome to the Knee Clinic. We are a private fee-for-service clinic. Please complete the following questionnaire. Your answers will help determine the level of care we are able to provide to you. If we do not believe your condition will respond satisfactorily, we will refer you to the appropriate health-care provider in a timely manner. Is this a WCB injury? Yes / No Please note that we do not accept WCB cases. Is this a motor vehicle injury? Yes / No

PERSONAL INFORMATION Name ____________________________ / ____________________________ / ____________ last first middle initial Personal Health # ___________________ - _______________ Male Female

Home Address ______________________________________________________________ City _____________________ Postal Code ___________________________ Email Address _________________________________________________ Phone numbers: Emergency Contact name and phone number: _____________________

Home ______________________________ Business __________________________ Mobile________________________ Physicians (G.P) Name, Address, Phone Number ____________________________________________________________________________________________________ Please be advised that in the interest of interprofessional communication, we will be in touch with your physician regarding the care you receive at our clinic. Is this a workplace injury? Yes / No *Please be advised that we do not accept WCB cases. Is your injury the result of a motor vehicle accident? Yes / No. If yes, additional intake forms are required. Birth Date _____ /____ /_______ Y M D Height: _______ Weight: _______ Marital Status M S W D

Occupation & Company Name___________________________________________________________ How did you first find out about the Knee Clinic? ________________________________________________

The healthcare team in this clinic meets regularly to discuss interdisciplinary co-treatment of our patients. If you do not wish us to discuss your case, please initial here: _____ Our clinic is committed to evidence-based practice and contributing to the scientific research community. All patient information used in research is kept strictly confidential and is used only with permission of the patient. Do you consent to allow your information to be used in future research? Yes No

HEALTH INFORMATION 1. Have you had any previous treatment to your knee? Yes No If so; reason? And with what approach? ______________________________________________________________________________________________

112-10333 Southport Rd SW, Calgary AB, T2W 3X6

www.kneeclinic.ca

2.

In your own words, please describe your chief complaint and when you first noticed the problem.

_______________________________________________________________________________
3. 4. 5. 6. What seems to make the problem better? _______________________________________________________ What seems to make the problem worse? _______________________________________________________ Does the pain radiate? Yes No What type of pain is it? (Please check) Sharp Stabbing Achy Burning Dull Diffuse Localized

7. 8.

At what time of the day does the pain seem to be at its worst? _____________________________________________ Does your knee lock? Yes No, Make cracking noises Yes No, Give out on you? Yes No

PHYSICAL HISTORY Please mark 1 beside the condition you have had in the past Please mark 2 beside the condition you presently have Musculoskeletal system knee problems upper back problems shoulder problems elbow/wrist problems low back problems Neck problems ankle/foot problems Arthritis Nervous system Numbness loss of feeling Headaches Dizziness Fainting Confusion Depression Forgetfulness Cardio-Vascular-Resp. chest pain high blood pressure difficult breathing persistent cough coughing phlegm/blood lung problems varicose veins diabetes hypoglycemia Genito-Urinary system painful urination excessive urine scanty urine discolored urine Female premenstrual syndrome vaginal discharge vaginal bleeding pregnancy breast pain, and/or lumps Gastrointestinal system poor appetite excessive hunger abdominal pain excessive thirst nausea/vomiting Diarrhea Constipation bloody/black stool liver/gallbladder trouble weight trouble Ear, Eyes, Nose, Throat eye problems vision problems ear discharge ear pain ear ringing hearing loss sore throat allergies hoarseness

If you have marked the presence of symptoms in the fields above you may consider consulting with our staff Naturopathic Doctor. A free 15 minute introductory consultation is available.

112-10333 Southport Rd SW, Calgary AB, T2W 3X6

www.kneeclinic.ca

Using the line scale provided below, rate the pain you are experiencing NOW!

0=====1=====2=====3=====4=====5=====6=====7=====8=====9=====10 No Pain Severe Pain

AREA(S) OF CONCERN Mark the areas on your body where you feel the described sensations. Use the appropriate symbol. Include all affected areas. Pain area(s) Aching \\\\\ \\\\\ Numbness ++++++ ++++++ Pins and Needles oooooooo oooooooo Burning bbbbb bbbbb Stabbing sssss sssss

Attire / Hygiene: Some treatments necessitate direct skin contact. Please bring shorts to each appointment and bathe before attending your appointment.

112-10333 Southport Rd SW, Calgary AB, T2W 3X6

www.kneeclinic.ca

FEES Initial Consultation: Regular Office Visit:

$ 250 $ 70

Re-Examination: Missed Office Visit:

$ 70 $40 (<24 hours notice)

Your first visit to the office includes both an initial consultation as well as an office visitor. This first visit may not consist of actual treatment at the discretion of the doctor. Re-examinations are done in the event of a six month time lapse between office visits.

Informed Consent to Chiropractic Treatment

There are risks and possible risks associated with manual therapy techniques used by doctors of chiropractic. In particular you should note:

a) While rare, some patients may experience short term aggravation of symptoms or muscle and
ligament strains or sprains as a result of manual therapy techniques. Although uncommon, rib fractures have also been known to occur following certain manual therapy procedures;

b) There are reported cases of stroke associated with visits to medical doctors and chiropractors.
Research and scientific evidence does not establish a cause and effect relationship between chiropractic treatment and the occurrence of stroke. Recent studies suggest that patients may be consulting medical doctors and chiropractors when they are in the early stages of a stroke. In essence, there is a stroke already in progress. However, you are being informed of this reported association because a stroke may cause serious neurological impairment or even death. The possibility of such injuries occurring in association with upper cervical adjustment is extremely remote;

c) There are rare reported cases of disc injuries identified following cervical and lumbar spinal
adjustment, although no scientific evidence has demonstrated such injuries are caused, or may be caused, by spinal adjustments or other chiropractic treatment;

d) There are infrequent reported cases of burns or skin irritation in association with the use of
some types of electrical therapy offered by some doctors of chiropractic. I acknowledge I have read this consent and I have discussed, or have been offered the opportunity to discuss, with my chiropractor the nature and purpose of chiropractic treatment in general, (including spinal adjustment), the treatment options and recommendations for my condition, and the contents of this Consent. I consent to the chiropractic treatment recommended to me by my chiropractor including any recommended spinal adjustments. I intend this consent to apply to all my present and future chiropractic care.

Dated this _______________ day of_________________, 20 ____________. _________________________________ Name (Please Print) _________________________________ Name of Witness (Please Print) _________________________ Patient Signature (Legal Guardian) _________________________ Witness Signature