ADIO Chiropractic
607-200 Southridge Drive
Okotoks, AB T1S 0B2
(403) 995-0855
maxlife@shaw.ca

Welcome to

ADIO Chiropractic!

 

Please complete the following thoroughly and accurately as this information will help Dr. Danny better understand your concerns and history. 

 

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We look forward meeting you and seeing what we can do to help!

ADIO Chiropractic
607-200 Southridge Drive
Okotoks, AB T1S 0B2
(403) 995-0855
maxlife@shaw.ca
First Name
Last Name
Address
City
Postal
Home Phone
Cell Phone
Alberta Health Care Number
Email
Gender
Birthdate
Height
Weight
Marital Status
Spouse
Names/Ages
Num. of Children
Emergency Contact
Relationship
Phone
ADIO Chiropractic
607-200 Southridge Drive
Okotoks, AB T1S 0B2
(403) 995-0855
maxlife@shaw.ca
How did you hear about us?
Prev. Chiropractor
X-Rays Taken?
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

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
ADIO Chiropractic
607-200 Southridge Drive
Okotoks, AB T1S 0B2
(403) 995-0855
maxlife@shaw.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 symptom radiate or travel to other parts of the body?
ADIO Chiropractic
607-200 Southridge Drive
Okotoks, AB T1S 0B2
(403) 995-0855
maxlife@shaw.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 your mobility?
Does this condition affect personal?
Does this condition affect sleep?
ADIO Chiropractic
607-200 Southridge Drive
Okotoks, AB T1S 0B2
(403) 995-0855
maxlife@shaw.ca
What else should we know about your current condition?
Rate the severity of your current pain from 0 to 10

No Pain
Excruciating Pain
Pain Duration
Current Medications
Supplements
Sleep Position
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:
ADIO Chiropractic
607-200 Southridge Drive
Okotoks, AB T1S 0B2
(403) 995-0855
maxlife@shaw.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

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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

ADIO Chiropractic
607-200 Southridge Drive
Okotoks, AB T1S 0B2
(403) 995-0855
maxlife@shaw.ca
Select options below indicating age at diagnosis and other relevant details.
Musculoskeletal
Neurological
Cardiovascular
Respiratory
Digestive
ADIO Chiropractic
607-200 Southridge Drive
Okotoks, AB T1S 0B2
(403) 995-0855
maxlife@shaw.ca
Sensory
Integumentary
Endocrine
Genitourinary
General
ADIO Chiropractic
607-200 Southridge Drive
Okotoks, AB T1S 0B2
(403) 995-0855
maxlife@shaw.ca
Personal Illness History
Surgery/Trauma History
ADIO Chiropractic
607-200 Southridge Drive
Okotoks, AB T1S 0B2
(403) 995-0855
maxlife@shaw.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

ADIO Chiropractic
607-200 Southridge Drive
Okotoks, AB T1S 0B2
(403) 995-0855
maxlife@shaw.ca
List four of your most desired health goals
Please read the following carefully before signing.

As a potential new patient, we feel it is important that you understand our office policies regarding,    how patients of this practice are cared for, and the various methods we offer to facilitate payment  for that care. Please read each policy carefully so there is no misunderstanding as to what you can expect as a patient of this practice, and what we expect in return. Once you have read Our Office Policies’, if you have any questions or any of these policies are unclear to you, and you would like further explanation before submitting your Application for Treatment, please let our reception know and a member of our staff will be happy to discuss them with you further. We believe it is in everyone’s best interests to provide potential new patients as much information as possible about how the doctors at this office practice chiropractic so that an informed decision can be made as to whether they wish to become a patient.

  Over time, individuals who are accepted, as patients at this office, gain a greater understanding as to the purpose of chiropractic. Since the majority of patient care occurs in an open bay area, patients have a unique opportunity to observe firsthand the positive results that are achieved and the benefits derived from being under chiropractic care. This knowledge and awareness reaps a positive environment that promotes healing and encourages families to maintain good health. We want your experience with us to be an exceptional one, so help us to help you and together we can make affirmative changes in your life and the lives of those you care about.

  PATIENT PRIVACY – Since the majority of patient care takes place in an open bay area it is important to understand that any conversations you have with the doctor can be overheard by other patients. In order to maintain patient privacy it is the policy of this practice to refrain from discussing any confidential matters with patients during treating hours while patients are being adjusted. If you have a confidential matter you wish to discuss please let us know and we will schedule time for you to speak to the doctor in a private consultation room. These consultations must be scheduled in advance.

  YOUR CARE - When a patient seeks chiropractic health care and we agree to provide that care, it is essential for the patient and the doctor to be working toward the same objective. Chiropractic care at ADIO Chiropractic is rendered primarily to minimize and reduce subluxations, which are a major interference to the expression of the body’s innate wisdom. The doctors use a myriad of techniques to accomplish this goal, including but not limited to manual chiropractic adjustments, Thompson drop technique, CLEAR institute adjusting, Impulse Instrument adjusting. It is important that you understand both the objective and the method(s) so there is no confusion or disappointment. Tremendous progress has been made in the rehabilitating and correction of spinal problems. Where in the past, chronic spinal structural problems could not be reversed or corrected, today they can. Your doctor will outline a course of treatment that will take you beyond simple pain relief, through two distinct phases of care to make a structural correction to your spine that will enable your central nervous system to function optimally, thereby improving you overall health.

  FIRST THINGS FIRST- Prior to receiving chiropractic care at this office, a health history and examination will be completed. Imaging studies as well as any other necessary diagnostics may also be ordered, to confirm the true nature of your condition and exact location of subluxations. The results of these procedures will aid in assessing your presenting problem, your overall health and, in particular, the condition of your spine. They will also assist the doctor in determining the type and amount of care you will need. All relevant findings will be reported to you along with care plan recommendations so that you can make the best possible decision regarding your health care needs. Our gold standard for care is to ensure the reduction of subluxation while teaching patients what they need to do in addition to being adjusted to maintain their health for a lifetime.

  PATIENT’S REPORT OF FINDINGS – To enhance your understanding of the chiropractic approach that will be used to manage your health, immediately following your first adjustment, you will be scheduled for a ‘Doctors Report of Findings’. The information you receive at this appointment will be both informative and clinically relevant to your case, therefore attendance is required for individuals who wished to become new patient of this practice. Because the results of your x-rays and all examinations as well as the doctors’ recommendations for care, will be discussed at that time, we strongly urge new patients to invite their spouse or significant other to attend. We know from experience that when a patient’s family understands the goals and objects of chiropractic care and how restoring and maintaining good health can affect their lives as well, they become infinitely supportive and helpful in making important decisions concerning treatment options.

 

I hereby acknowledge having read the ‘Our Office Policies’ document. I am able to print or save this document if needed for future reference. I further acknowledge that any concerns regarding these ‘Policies‘ as well as all my questions have been answered by a qualified member of the staff to my complete satisfaction. My signature below recognized my understanding of this ‘Notice‘.

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Today's Date: 11 Dec 2017