Name
Home Phone
Work Phone
E-mail Address
How did you find out about us?
Organization / Company U of A Government of Alberta School Board Epcor Atco Other
Occupation
Insurance Provider Sunlife Blue Cross Cooperators Other
Which treatments have you had before? Massage Acupuncture
Which treatments are covered by your insurance? Massage Acupuncture
Reason for your visit:
How long have you had this condition?
What seems to be the initial cause?
Is the condition getting worse? Yes No
Does the condition disrupt any of the following activities? Work Sleep Other
What seems to make it better?
What seems to make it worse?
Are you under the care of a physician now? Yes No
If yes, why?
Who is your physician?
Do you have insurance coverage? Yes No
Primary health concerns and complaints:
Most important health problems (List in order of importance):
Do you have any contagious diseases at this time? (Hepatitis, HIV, Flu, TB, etc...)
Check boxes for any conditions you currently have:
Check boxes for any conditions you have had in the past:
List any other medical conditions or medical history:
Check boxes for any items that apply to you:
How many glasses of water do you drink per day?
Describe your regular exercise:
Other head or neck problems:
Bowel problems:
Other problems:
Other hair or skin problems:
Other:
Age of first menses
Duration of flow
Last pap test
Last period
Number of pregnancies
Number of live births
Number of premature births
Age at menopause
Please list any other health issues:
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