Lifetime Wellness Center
3090 Dougall Ave., Suite 401
Windsor, ON N9E 1S4
(519) 250-6288
admin@chiropractorwindsor.com

Welcome to our office!

To ensure your visit with us is a pleasant one, here are the procedures you can expect during the next 60 minutes.

 

Paperwork Complete this brief questionnaire and your health form to help us get to know you.
Consultation You will meet the Doctor and our new patient advocate. The Doctor will review your history and determine if yours is a chiropractic case.
Examination Standard physical, orthopedic, neurological and chiropractic tests will be performed to determine the cause(s) of your subluxation(s).
Spinal Images The Doctor will send you for your updated x-rays if deemed necessary.
Correlation Before proper care can be rendered the Doctor will study your examination findings. Later, you will see your x-rays, review your findings and receive specific recommendations from the Doctor.
Lifetime Wellness Center
3090 Dougall Ave., Suite 401
Windsor, ON N9E 1S4
(519) 250-6288
admin@chiropractorwindsor.com
First Name
Last Name
Address
City
Postal
Home Phone
Cell Phone
Other Phone
Email
Gender
Birthdate
Height
Weight
Shoe Size
Marital Status
Spouse
Names/Ages
Num. of Children
Emergency Contact
Relationship
Phone
Lifetime Wellness Center
3090 Dougall Ave., Suite 401
Windsor, ON N9E 1S4
(519) 250-6288
admin@chiropractorwindsor.com
How did you hear about us?
Family Physician
Physician Phone
Date of Last Visit
Work Status
Employer
Employer Phone
Occupation
Employer Address
Have you missed work due to this injury?
Missed work start date
Return or anticipated return date
Extend. Health Cov.

Primary
Company
Policy #
Group #
Who Carries this Policy?
Insured's:
Name
Birth Date
Gender
Patient Address
Phone
Address
City
Postal
Prov
Employer
Emp. Phone
Secondary
Company
Policy #
Group #
Who Carries this Policy?
Insured's:
Name
Birth Date
Gender
Patient Address
Phone
Address
City
Postal
Prov
Employer
Emp. Phone
Lifetime Wellness Center
3090 Dougall Ave., Suite 401
Windsor, ON N9E 1S4
(519) 250-6288
admin@chiropractorwindsor.com
The symptoms that have prompted you to seek care today include:
Have you seen other doctor(s) for this condition?
Prior Interventions
What is the condition related to?
When did your problem first start?
Have you had this condition before?
Does the pain radiate or travel to other parts of the body?
Lifetime Wellness Center
3090 Dougall Ave., Suite 401
Windsor, ON N9E 1S4
(519) 250-6288
admin@chiropractorwindsor.com
Does anyone from your family suffer from the same condition?
What makes the condition worse?
What makes the condition better?
Does this condition affect employment?
Does this condition affect recreation?
Does this condition affect household?
Does this condition affect personal?
Does this condition affect sleep?
Lifetime Wellness Center
3090 Dougall Ave., Suite 401
Windsor, ON N9E 1S4
(519) 250-6288
admin@chiropractorwindsor.com
What else should we know about your current condition?
Rate the severity of your pain from 0 to 10

No Pain
Excruciating Pain
Pain Duration
Current Medications
Supplements
Sleep Position
Hours of sleep per night (1-24)
Have you had x-rays in the last six months?
I realize that x ray examinations may be hazardous to an unborn child. I certify to the best of my knowledge I am not pregnant.
Last Cycle:
Lifetime Wellness Center
3090 Dougall Ave., Suite 401
Windsor, ON N9E 1S4
(519) 250-6288
admin@chiropractorwindsor.com
Type of Pain
Front Head

Type of Pain
Front Face

Type of Pain
Front Left Jaw

Type of Pain
Front Right Jaw

Type of Pain
Front Right Neck

Type of Pain
Front Left Neck

Type of Pain
Front Left Chest

Type of Pain
Front Right Chest

Type of Pain
Front Right Ribs

Type of Pain
Front Left Ribs

Type of Pain
Front Abdomen

Type of Pain
Front Pelvis

Type of Pain
Front Right Hip

Type of Pain
Front Left Hip

Type of Pain
Front Right Thigh

Type of Pain
Front Left Thigh

Type of Pain
Front Right Knee

Type of Pain
Front Left Knee

Type of Pain
Front Right Lower Leg

Type of Pain
Front Left Lower Leg

Type of Pain
Front Right Ankle

Type of Pain
Front Left Ankle

Type of Pain
Top of Right Foot

Please specify specific areas

Type of Pain
Top of Left Foot

Please specify specific areas

Type of Pain
Front Right Shoulder

Type of Pain
Front Left Shoulder

Type of Pain
Front Right Upper Arm

Type of Pain
Front Left Upper Arm

Type of Pain
Front Right Elbow

Type of Pain
Front Left Elbow

Type of Pain
Front Right Forearm

Type of Pain
Front Left Forearm

Type of Pain
Front Right Hand

Please specify specific areas

Type of Pain
Front Left Hand

Please specify specific areas

Type of Pain
Front Right Wrist

Type of Pain
Front Left Wrist

Type of Pain
Back of Head

Type of Pain
Back Right Neck

Type of Pain
Back Left Neck

Type of Pain
Upper Back

Type of Pain
Back Right Shoulder

Type of Pain
Back Left Shoulder

Type of Pain
Mid-Back

Type of Pain
Back Right Ribs

Type of Pain
Back Left Ribs

Type of Pain
Lower Back

Type of Pain
Back Right Hip

Type of Pain
Back Left Hip

Type of Pain
Back Right Glute

Type of Pain
Back left Glute

Type of Pain
Back Right Thigh

Type of Pain
Back Left Thigh

Type of Pain
Back Right Knee

Type of Pain
Back Left Knee

Type of Pain
Back Right Lower Leg

Type of Pain
Back Left Lower Leg

Type of Pain
Back Right Ankle

Type of Pain
Back Left Ankle

Type of Pain
Bottom of Right Foot

Please specify specific areas

Type of Pain
Bottom of Left Foot

Please specify specific areas

Type of Pain
Back Right Upper Arm

Type of Pain
Back Left Upper Arm

Type of Pain
Back Right Elbow

Type of Pain
Back Left Elbow

Type of Pain
Back Right Forearm

Type of Pain
Back Left Forearm

Type of Pain
Back Right Hand

Please specify specific areas

Type of Pain
Back Left Hand

Please specify specific areas

Type of Pain
Back Right Wrist

Type of Pain
Back Left Wrist

Lifetime Wellness Center
3090 Dougall Ave., Suite 401
Windsor, ON N9E 1S4
(519) 250-6288
admin@chiropractorwindsor.com
Select options below indicating age at diagnosis and other relevant details.
Musculoskeletal
Neurological
Cardiovascular
Respiratory
Digestive
Lifetime Wellness Center
3090 Dougall Ave., Suite 401
Windsor, ON N9E 1S4
(519) 250-6288
admin@chiropractorwindsor.com
Sensory
Integumentary
Endocrine
Genitourinary
General
Lifetime Wellness Center
3090 Dougall Ave., Suite 401
Windsor, ON N9E 1S4
(519) 250-6288
admin@chiropractorwindsor.com
Personal Illness History
Surgery/Trauma History
Lifetime Wellness Center
3090 Dougall Ave., Suite 401
Windsor, ON N9E 1S4
(519) 250-6288
admin@chiropractorwindsor.com
Social History
Family History
Mother
Age
Age at Death
Health
Illness
Father
Age
Age at Death
Health
Illness
Sister
Age
Age at Death
Health
Illness
Brother
Age
Age at Death
Health
Illness

Lifetime Wellness Center
3090 Dougall Ave., Suite 401
Windsor, ON N9E 1S4
(519) 250-6288
admin@chiropractorwindsor.com
What is the most significant thing you can do to improve your health?
How committed are you at achieving your maximum health potential?

Not Interested
Very Interested
How do you want us to handle your problem?
Please read the following carefully before signing.

                  CLINICAL CONSENT, PRIVACY & INSURANCE POLICIES

Consent to Chiropractic Care & to the Collection, Use, and Disclosure of Personal Information

 

INFORMED CONSENT TO CHIROPRACTIC ADJUSTMENTS AND CARE:

Physicians, Chiropractors, Osteopaths and Physiotherapists are required to advise patients of benefits and risks including sprain/strain, rib fracture, disc herniation and neck problems of the following: There have been very rare incidents of injury to the vertebral artery during the course of treatment. This has caused strokes or stroke like occurrences, which are usually of a temporary nature. The chances of this happening are rare. Tests, with or without x-rays have been performed on you to minimize these risks to yourself. Chiropractic is considered to be one of the safest and most effective forms of therapy for neck conditions. The Chiropractor may also scan your feet for custom made orthotics to determine if you may benefit from them. The fee for this scan is included with your New Patient Examination. The Chiropractor may also suggest other treatments, including: Low Level Lasers, Shockwave Therapy & Kinesio Taping in addition to Chiropractic adjustments. All of the services are none invasive and promote faster healing and pain relief. As Chiropractors we do not claim to treat any specific diseases or ailments. (This includes: High Blood Pressure, Diabetes, ADHD e.c.t). We simply work with the spine to attain optimal alignment and nervous system function. If you have any questions about this, please ask your Chiropractor.

 

PRIVACY POLICY:

In accordance with the privacy act effective January 2004, we must ask for your informed consent. This means we want you to understand what we do with personal information. Your signature below allows us to obtain this information to open a confidential file for you. This is the only reason we collect your personal information. I understand that to provide me with Chiropractic goods and services, Lifetime Wellness Center will collect some personal information about me (e.g.: telephone number, birth date, address, etc.).

 

We use and disclose your personal health information to:

·          treat and care for you,

·          plan, administer and manage our internal operations,

·          conduct quality improvement activities (such as sending patient satisfaction surveys)

·          teach,

·          compile statistics,

·          comply with legal and regulatory requirements, and

·          fulfill other purposes permitted by law.

 

We take steps to protect your personal health information from theft, loss and unauthorized access, copying, modification, use, disclosure and disposal.  We conduct audits and complete investigations to monitor and manage our privacy compliance.  We take steps to ensure that everyone who performs services for us protect your privacy and only use your personal health information for the purpose you have consented to. I understand that, as explained in the Policies and Procedures for Personal Information, there are some rare exceptions to the commitments.

 

INSURANCE POLICY:

Direct billing is available for patients that have chiropractic coverage for regular monthly maintenance and, those who have purchased a pre-paid treatment package. Due to the complex  nature of co-payments, deductibles and changing benefit plans, you will be responsible to pay the remaining balance.

 

* Please read and agree to the terms
Signature
Today's Date: 20 Aug 2017