Patient Assessment Form Name* First Last Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Home phone or cell number*Email* Date of Birth* MM slash DD slash YYYY Your Age* Your Gender* Your Occupation* Do you have any medical conditions?* Yes No If yes, please specify below:Are you currently taking any medications?* Yes No If yes, please specify below:Do you have any allergies?* Yes No If yes, please specify below:What is the chief complaint(s) you are seeking treatment for?* Was there a mechanism or event that lead to this condition or injury?* When did this condition or injury occur (date if possible)? Are you currently receiving any treatment for this condition/injury?* Yes No Have you seen your doctor in regards to this condition/injury?* Yes No Have you had any testing or imaging done for this condition/injury (i.e. x-ray, MRI, CTscan, blood work)?* Yes No If yes, please list what tests have been done.Are you in pain?* Yes No If yes, where is the pain located? What aggravates the pain? What relieves the pain? How would you describe the pain i.e. sharp, dull, achy, throbbing? Does the pain radiate? Yes No If yes, where does the pain radiate from and to? What is the severity of the pain on a pain scale from 1 to 10?123456789101 is no pain, 10 is the worst painHave you had a fall(s) on your buttocks or tailbone? Yes No Have you ever incurred a head injury i.e. concussion? Yes No Have you been involved in an MVA or whiplash type trauma? Yes No Have you incurred any other injury in the past? Yes No If yes, please list injuries, dates of injuries and if you received medical or therapeutic treatment. Have you had any surgery including dental (i.e. wisdom teeth)? Yes No If yes, please list the date of surgery and what the surgery was for: Do you have any scars from trauma or surgery? Yes No If yes, where is the scar(s) located? Is there a family medical history of illness on your mother's side? On your father's side? Please list exercise/activities/sports you participate in and how frequently: What time are you in bed and asleep? What time do you wake up in the morning? Do you wake up during the night? If yes, is there a consistent time(s) you wake up at? Do you wake up in the morning feeling refreshed? Yes No On a scale of 1 to 5 (1 is none, 5 is very) what level of stress do you feel you experience on a daily basis?12345Diet: please list general idea of what breakfast, lunch, dinner and snacks you consume:How much water do you drink a day? What other beverages do you consume? (i.e. coffee, tea, juice, alcohol, sports/energy drinks): Do you have any dietary restrictions? If yes, please list Are you a smoker? Yes No How many cigarettes per day? Please check if you are presently experiencing or have experienced symptoms in these areas? Neck Upper back Mid back Lower back Hips Chest Arms Hands Elbows Wrists Legs Knees Ankles Feet broken bones: Internal pins/wires/screws: History of headaches Tenson Migraine Tooth Jaw Ear pain Frequency of headaches: Other type of headaches: History of eyes, ears, nose, and throat conditions? Glasses/contacts Eye conditions Ear infections Hearing loss Ringing in ears Nasal obstruction Nosebleeds Laryngitis Other: History of respiratory conditions? Chronic cough Bronchitis Oasthma Emphysema Pneumonia Sinus problems Shortness of breath Other: History of cardiovascular conditions? High blood pressure Low blood pressure Phlebitis/DVT Pulmonary/emboli Pacemaker Heard disease Angina Chronic congestive heart failure Heart attack date: MM slash DD slash YYYY Stroke date: MM slash DD slash YYYY Other: History of gastrointestinal conditions? Gastroenteritis Colitis Crohn’s disease Gastroesophageal Reflux Constipation Diarrhea Flatulence Bloating Gurgling Stomach ulcer Burping Vomiting Irritable bowel syndrome Other: History of urogenital conditions? Urinary tract infections Urine discoloration Increased urinary frequency Blood in urine Flank pain Kidney disease Dialysis Women: Painful periods Cramps PMS Regular cycle Heavy periods Pregnant Breast pain Breast reduction/augmentation Other: If pregnant, when is your due date? MM slash DD slash YYYY Men: Prostatitis Prostate cancer Other: Infectious diseases: Hepatitis Tuberculosis Infectious skin conditions HIV/AIDS Other: Skin conditions: Bruise easily Herpes Varicose veins Athletes foot Warts Loss of sensation Eczema Psoriasis Other skin conditions? Other conditions: Epilepsy Vision loss Hemophilia Insomnia Chemotherapy Radiation Anaphylaxis Skin irritation Family history of allergies/hypersensitivities Arthritis: type OA/RA Osteopenia Osteoporosis Mental conditions Anxiety Depression Neurological conditions: Cancer (type): Diabetes (what type?) How did you hear about me?*GoogleFacebookYouTubeReferral from a medical professionalWord of Mouth Consent To Treatment Within the Athletic Therapist and Osteopathic Manual Practitioner's scope of practice, a treatment includes manual therapy where the practitioner may place their body or hands in contact with your body to administrator treatment. Areas that may be treated, depending on your condition, could include your pelvis, chest wall, abdomen or work within your mouth. If treatment is required within the mouth, such as in the case of TMJ dysfunction or injury, a latex-free glove will be worn. You may be asked to remove clothing in the area to be treated to help facilitate treatment but this will be up to your leave of comfort. If you do not feel comfortable with a given technique being used within your treatment please let Carolyn know immediately. This technique will then be discontinued or modified to your level of comfort and satisfaction. Also following a treatment you may experience some mild soreness that should resolve in 1 to 2 days. If it does not please notify Carolyn. A cancellation/no show fee, in the amount of your full appointment fee, will be applied to any missed appointment without a 24 hours notice given. By signing this consent form you are giving your consent to Carolyn Zepf in the capacity to provide treatment on your person and that you understand and agree to the terms outlined above. Name First Last Signature*Date MM slash DD slash YYYY Δ
