GLENMORE CHIROPRACTIC -Shockwave Therapy

Confidential Patient Information

Is this an ICBC/Worksafe injury? □ Yes □ No If YES please note that we do NOT deal directly with ICBC or Worksafe.for billing.

Name: ______

Address:______

City: ______Province: ______Postal Code: ______

Phone:______

E-mail: ______***WE DO NOT DO PHONE REMINDERS. Your email address will ONLY be used for sending appointment reminders or to advise of changes at the clinic or with your appointment; insurance claim/account status or follow up for treatments. We will NOT share your email or any personal information with anyone. If you do not wish to receive email reminders please check this box ( ) If at any time you wish to be removed from our email list please notify the office by phone or email and we will remove you immediately.

Employer: ______Type of work: ______

Date of birth: ______Age: ______□ Male □ Female

Marital Status: □ M □ S □ D □ W

Name of Emergency Contact: ______Phone: ______

Family Physician: ______

How did you hear about our office? ______

1. What is your main complaint(s)? ______

2. How did this condition begin? □ Work injury □ Sports injury □ Auto accident □ Home accident □ Chronic (long-term) discomfort □ Other (please describe)

______

3. How long have you suffered with this condition: _____ Day (s) _____Week (s) _____ Month (s) _____ Year (s)

4. Have you experienced previous episodes of this condition? □ Yes □ No

5. Has this condition: □ Gotten worse □ Gotten better □ Stayed constant □ Comes & goes Next page….

6. Character of the condition: □ Sharp □ Dull □ Achy □ Burning □ Numbness □ Pins & needles

7. Aggravating factors: □ Sitting □ Standing □ Bending □ Lifting □ Walking □ Lying

□ Other (please describe) ______

8. Relieving factors: □ Bed rest □ Ice □ Heat □ Medication □ Massage therapy

9. Does this condition interfere with: □ Work □ Family □ Sports/hobbies □ Other: ______

10. What other types of treatment have you tried: □ Acupuncture □ Medication □ Physiotherapy □ Massage Therapy

Indicate pain severity by circling one of the numbers below, note body area on model and on list:

1.______1. ______

2.______2. ______

3.______3. ______

DOCTOR’S NOTES: next page… Provide other treatments you have received for this condition. ______Please list any past surgeries or injuries. ______Please list any medications (herbal), vitamins, and minerals that you are currently taking. ______

Check any of the following you have had in the last 6 months: ( ) Cortisone therapy up to 6 weeks before first treatment in the target area ( ) Pacemaker ( ) Tumor disease, carcinoma patient ( ) Acute inflammation ( ) Blood thinning medications especially Marcumar ( ) Heart problems ( ) Blood pressure problems ( ) Cancer ( ) Diabetes ( ) Other ______

Are you pregnant ( ) Yes ( ) No ( ) Not Sure

Please review and sign the consent for treatment (below) in front of the doctor at your first appointment.

Informed Consent for Shockwave EPAT Therapy Treatment

Shockwave can trigger an inflammatory response which is the body’s natural process of healing, for this reason do not use any anti-inflammatory medications or use heat or ice. If experiencing any pain this should subside within 24 hours. To help with the pain you can take Advil or Tylenol if necessary. Although the short-term effects alone are exceptional, the long-term benefits of this treatment may take up to 3 to 4 months. Even if it feels good, we recommend decreased activity for 48 hrs following the treatment.

Possible Side effects: Swelling, reddening, hematomas, peteciae, pain, skin lesions after previous cortisone therapy. These side effects generally abate after 5-10 days

PLEASE SIGN IN FRONT OF DOCTOR: Date:______

Patient Signature______

Doctor Signature ______

PLEASE NOTE: Payment for Treatments are Non-Refundable. For direct billing information please see receptionist.