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Medical Info
Primary Complaint
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General Health
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Current Treatment
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Medications
Injuries
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Additional Info
Insurance Info
Insurer's Name
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Email Address
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Claims / Benefit
Conditions
TMJ (Jaw)
Ear Pressure
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Ear Ringing
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Ear Stuffiness
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Grinding
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Clenching
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Jaw Pain
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Difficulty Chewing
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Locking
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Difficulty Opening Jaw
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Morning Stiffness
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Ear Blockage
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Energy
Does your energy fluctuate?
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How long do you sleep on average?
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Is your energy constant?
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Do you struggle with insomnia?
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HT/SI (Fire)
Chest Pain
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Heart Palpitations
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Lymph Swelling
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Skin Rash
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Health Questions
Vertigo
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COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
Willing to wash hands before entering clinic
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Willing to wash hands before leaving clinic
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Willing to wear face mask in the clinic
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Agree to wear face mask during treatment
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Have you been tested for COVID?
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Fever Over 100.4 degrees
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Headaches
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New Onset of Cough
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Worsening Chronic Cough
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Sore Throat
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Shortness of Breath
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Difficulty Breathing
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Decrease or sudden loss of taste and smell
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Unexplained Fatigue/Malaise/Muscle Aches (Myalgia)
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Chills
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Pink eye (conjunctivitis)
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Nasal or sinus congestion
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Runny nose/nasal congestion without other known cause
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Nausea
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Vomiting
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Diarrhea
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Recent travel outside your province within the past 14 days
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Oncology
Cancer Type
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Date of Diagnosis
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Location
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Status
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Treatment: Surgery
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Date of Surgery
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Lymph Nodes Removed
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Side Effects of Surgery
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Reconstruction Date
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Treatment: Chemotherapy
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Number of Chemo Treatments
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Side Effects of Chemo
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Treatment: Radiation
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Number of Radiation Treatments
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Area of Radiation
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Nodes Irradiated
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Side Effects of Radiation
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Other Treatments
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Medical Devices
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Nausea
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Vomiting
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Mouth Sores
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Weight Loss
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Weight Gain
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Bone Pain
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Adhesions
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Incision
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Pressure Sensitivity
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Pain
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Former Injuries
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Loss of Movement
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Abnormal Skin Sensation
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Memory Problems
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Edema
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Low Platelet
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Low White Count
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Blood Clot
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Excessively Warm/Cold
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Lymphedema
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Heart Condition
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Lung Condition
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Dry Skin
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Fragile Skin
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Radiation Skin Reaction
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Hair Loss
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Fatigue
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Systemic Infection
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Infectious Condition
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Current Tumour
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Enlarged Lymph Nodes
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Enlarged Spleen
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Enlarged Liver
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Radioactivity
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Female Health
Pelvic Pain
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Area of Complaint
Neck
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Left Side of Neck
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Right Side of Neck
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Upper Back
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Left Side of Upper Back
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Right Side of Upper Back
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Mid Back
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Left Side of Mid Back
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Right Side of Mid Back
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Low Back
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Left Side of Low Back
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Right Side of Low Back
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Chest
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Abdomen
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Left Arm
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Right Arm
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Left Shoulder
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Right Shoulder
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Left Elbow
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Right Elbow
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Left Wrist
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Right Wrist
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Left Hand
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Right Hand
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Left Leg
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Left Thigh
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Left Calf
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Right Leg
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Right Thigh
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Right Calf
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Left Gluteal
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Right Gluteal
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Left Hip
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Right Hip
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Left Groin
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Right Groin
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Left Knee
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Right Knee
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Left Ankle
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Right Ankle
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Left Foot
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Right Foot
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Sacrum
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Tailbone (coccyx)
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Brain Disorders
PTSD
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Bipolar Disorder
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Schizophrenia
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Borderline Personality Disorder
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Sleep Disorder
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Claustrophobia
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Depression
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Social Anxiety Disorder
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Generalized Anxiety Disorder
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Acute Stress Disorder
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Obsessive Compulsive Disorder
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ADD
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Obsessive Compulsive Personality Disorder
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ADHD
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Panic Disorder
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Autism
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Headaches
Rebound
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Sinus
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Tension
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Chronic Daily Headache
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Cluster
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Headaches
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Migraines
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Other Headaches
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Cardiovascular
Low Blood Pressure
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Chest Pain
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Lymphedema
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Cold Feet
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Pericarditis
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Cold Hands
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Phlebitis
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Heart Attack
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Raynaud Disease
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Heart Condition
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Rheumatic Heart Disease
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Heart Disease
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Stroke
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Blood Pressure
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High Blood Pressure
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Hyperlipidemia
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Swelling
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Cardiac Arrhythmia
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Other Cardiovascular
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Respiratory
Shortness of Breath
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Musculoskeletal
Amyotrophic Lateral Sclerosis (ALS)
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Recti Diastasis
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Carpal Tunnel Syndrome
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Tendonitis/Bursitis
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Fibromyalgia
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Myasthenia Gravis
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Ankylosing Spondylitis
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Scleroderma
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Chronic Fatigue Syndrome
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Torticollis
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Fracture
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Osgood-Schlatter Disease
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Osteoarthritis
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Arthritis
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Scoliosis
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Chronic Myofascial Pain Syndrome
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Whiplash
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Gout
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Osteomalacia
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Artificial Joints / Special Equipment
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Sinus Problems
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Compartment Syndrome
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Hereditary/Congenital Deformity
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Osteoporosis
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Baker's Cyst
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Spasms / Cramps
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Degenerative Disk Disease
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Jaw Pain (TMJD)
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Paget Disease
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Bone Disease
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Spondylolisthesis
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Dislocation
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Joint Injury
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Plantar Fasciitis
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Bone or Joint Disease
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Strain/Sprain
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Dupuytren's Contracture
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Joint Stiffness / Swelling
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Adhesive Capsulitis
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Psoriatic Arthritis
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Broken Bone / Fracture
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Temporomandibular Joint Dysfunction
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Ehlers-Danlos Syndrome
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Muscular Dystrophy
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Other Musculoskeletal
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Gastrointestinal
Ulcerative Colitis
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Neurological
Epilepsy
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Numbness
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Sciatic Pain
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Shingles
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Brain Disorder
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Sleeping Disorders
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Brain Injury
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Tingling
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Chronic Pain Disorder
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Dizziness
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Immune
Non-Hodgkin Lymphoma
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Rheumatoid Arthritis
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Sjogren's Syndrome
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Allergies
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Hodgkin Lymphoma
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Leukemia
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Lupus
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Other Immune
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Skin
Acne
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Allergic Dermatosis
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Alopecia
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Bruise Easily
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Eczema
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Moles
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Psoriasis
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Dry Skin
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Oily Skin
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Mature Skin
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Sensitive Skin
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Sun Damage
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Endocrine
Hyperthyroidism
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Hypothyroidism
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Hearing
Hearing Loss
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Family History
Arthritis
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Cancer
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Cardiovascular
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Diabetes
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Respiratory
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Blood
HIV/AIDS
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Thrombosis/Embolism
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Kidney
Bladder Disorder
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Chronic Kidney Disease
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Congenital Kidney Disease
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Reproductive
Menopause
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Menstrual Cycle Disorder
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General Injury Related Questions
What is the next competition/challenge?
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Previous sports-related injuries?
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Treatment of previous injury?
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Physical Therapy
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Chiropractic
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OTC medications
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Pain medications or steroids
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Surgery (type/year)
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Complications from that injury?
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Prenatal (check boxes to enter details below)
Due Date
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Trimester
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Weeks Pregnant
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Number of previous pregnancies/births?
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Anemia
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Bladder Infection
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Blood Clot (Phlebitis)
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Abdominal Cramping
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Diabetes
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Edema/Swelling
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Leg Cramps
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Miscarriage
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Sciatica
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Twins or More
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Accident Info
Date of Injury
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Which State?
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MVA Claim
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Workers Comp Claim
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Crime Victim Comp.
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