Skywalk Health Inc.
211-393 Portage Ave
Winnipeg, MB R3B 3H6
(204) 505-7007
hello@skywalkhealth.ca

Welcome to Skywalk Chiropractic & Massage

Our practice is committed to providing the highest quality patient care and helping you to achieve your personal health goals.

 

The following form is for you to complete before your first visit.  This provides a general report of who you are, your past health history, and the current condition for which you are seeking treatment that your health care provider can review in preparation for your first visit.

 

You may choose to complete this from the comfort of your own home or office OR you may also complete it upon arrival for your first visit.  If you prefer the latter option, please be prepared to arrive at least 10-15 min early for your appointment.

Skywalk Health Inc.
211-393 Portage Ave
Winnipeg, MB R3B 3H6
(204) 505-7007
hello@skywalkhealth.ca
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
Skywalk Health Inc.
211-393 Portage Ave
Winnipeg, MB R3B 3H6
(204) 505-7007
hello@skywalkhealth.ca
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
Skywalk Health Inc.
211-393 Portage Ave
Winnipeg, MB R3B 3H6
(204) 505-7007
hello@skywalkhealth.ca
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?
Skywalk Health Inc.
211-393 Portage Ave
Winnipeg, MB R3B 3H6
(204) 505-7007
hello@skywalkhealth.ca
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?
Skywalk Health Inc.
211-393 Portage Ave
Winnipeg, MB R3B 3H6
(204) 505-7007
hello@skywalkhealth.ca
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:
Skywalk Health Inc.
211-393 Portage Ave
Winnipeg, MB R3B 3H6
(204) 505-7007
hello@skywalkhealth.ca
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

Skywalk Health Inc.
211-393 Portage Ave
Winnipeg, MB R3B 3H6
(204) 505-7007
hello@skywalkhealth.ca
Select options below indicating age at diagnosis and other relevant details.
Musculoskeletal
Neurological
Cardiovascular
Respiratory
Digestive
Skywalk Health Inc.
211-393 Portage Ave
Winnipeg, MB R3B 3H6
(204) 505-7007
hello@skywalkhealth.ca
Sensory
Integumentary
Endocrine
Genitourinary
General
Skywalk Health Inc.
211-393 Portage Ave
Winnipeg, MB R3B 3H6
(204) 505-7007
hello@skywalkhealth.ca
Personal Illness History
Surgery/Trauma History
Skywalk Health Inc.
211-393 Portage Ave
Winnipeg, MB R3B 3H6
(204) 505-7007
hello@skywalkhealth.ca
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

Skywalk Health Inc.
211-393 Portage Ave
Winnipeg, MB R3B 3H6
(204) 505-7007
hello@skywalkhealth.ca
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.

Office Policies

 Please review these important policies regarding our office.

Your Account

Please be advised that you are responsble for the fees for all services rendered to you and charged to your account unless other arangements have been made, such as direct billing of services to Maitoba Public Insurance, Workers Compensation Board of Manitoba, Manitoba Health, or a 3rd party insurance.  All fees are due the day the services are provided and may be paid by cash, debit, or credit card.  All accounts left outstanding for more than 30 days will be subject to a 4% interest charge compounded monthly.

Private Insurance

As a courtesy and convenience to you we submit claims to your insurance company directly whenever possible.  We do require that you pay your co-payment and/or deductible at the time services are rendered.  Please note that all insurance companies and plans are different.  We will work our hardest to insure the accuracy of your claims, but payment by insurance is never guaranteed.  Your insurance policy is a contract between you and the insurance company.  We are not a party to that contract which may prevent us from submitting claims, obtaining the necessary information, or assigning payment.  We will do our best to help you, but you are ultimately responsible for the costs of treatment.

 

Massage Appointment Cancellation Policy

Massage therapy appointments require 24-hours notice for any changes or cancellation of the appointment to avoid a cancellation fee of 50% of the services booked.  This cancellation policy does not apply to Chiropractic appointments, however we do ask that you give as much notice as possible if you need to make any changes as a courtesy to our other clients.

* Please read and agree to the terms
Signature
Today's Date: 22 Oct 2019