Wilson Health Service
Wilson Health Services
6-210 Pinebush Road, Cambridge, 519-624-80

www.wilsonhealth.ca

Welcome

Thank you for choosing Wilson Health Services for your healthcare needs. We are honoured you have chosen us to fullfill the important role in caring for you and your family.

 

Our clinic requires registration for all our new patients. This allows our practitioners to review your health information thus decreasing your wait time when you arrive for your visit.

 

Please remember that all extended health services are not covered by OHIP and payment in full is requiered at the time of treatment. If devices are made to aid in the management of a problem the patient is responsible for the payment at the end of the treatment. In the case of custom foot orthotics, a deposit is requiered upon casting and is due upon fitting.

  

We will gladly make adjustments to custom foot orthotics during the initial 3 months of wear to ensure devices are achieving the intended functions. There are no refunds on custom devices.

 

We requiere 24 hour notice to change or cancel a scheduled appointment. 100% of the fees will be due for no show or late notice appointment cancellations/changes.

 

Cash, Cheque, Debit, Visa and Mastercard are acceptable forms of payment.

Wilson Health Service
Wilson Health Services
6-210 Pinebush Road, Cambridge, 519-624-80

www.wilsonhealth.ca
First Name
Last Name
Address
City
Postal
Home Phone
Cell Phone
Other Phone
Email
Gender
Birthdate
Height
Weight
Shoe Size
Marital Status
Emergency Contact
Emergency Contact #
Wilson Health Service
Wilson Health Services
6-210 Pinebush Road, Cambridge, 519-624-80

www.wilsonhealth.ca
How did you hear about us?
Family Physician
Physician Phone
Date of Last Visit
Work Status
Employer
Occupation
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
Wilson Health Service
Wilson Health Services
6-210 Pinebush Road, Cambridge, 519-624-80

www.wilsonhealth.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?
Wilson Health Service
Wilson Health Services
6-210 Pinebush Road, Cambridge, 519-624-80

www.wilsonhealth.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?
Wilson Health Service
Wilson Health Services
6-210 Pinebush Road, Cambridge, 519-624-80

www.wilsonhealth.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
Hours of sleep per night (1-24)
Have you had x-rays, MRI's or CT Scans 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:
Wilson Health Service
Wilson Health Services
6-210 Pinebush Road, Cambridge, 519-624-80

www.wilsonhealth.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

Wilson Health Service
Wilson Health Services
6-210 Pinebush Road, Cambridge, 519-624-80

www.wilsonhealth.ca
Select options below indicating age at diagnosis and other relevant details.
Musculoskeletal
Neurological
Cardiovascular
Respiratory
Digestive
Wilson Health Service
Wilson Health Services
6-210 Pinebush Road, Cambridge, 519-624-80

www.wilsonhealth.ca
Sensory
Integumentary
Endocrine
Genitourinary
General
Wilson Health Service
Wilson Health Services
6-210 Pinebush Road, Cambridge, 519-624-80

www.wilsonhealth.ca
Personal Illness History
Surgery/Trauma History
Wilson Health Service
Wilson Health Services
6-210 Pinebush Road, Cambridge, 519-624-80

www.wilsonhealth.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

Wilson Health Service
Wilson Health Services
6-210 Pinebush Road, Cambridge, 519-624-80

www.wilsonhealth.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/What are your long term expectations from your practitioner?
Please read the following carefully before signing.

We would like your informed consent. This means that we want you to understand the services we hope to provide to you & the cost involved, and what we do with personal information we obtain about you/ if you have any questions, please ask.

 Physicians, Chiropractors, Osteopaths, and Physiotherapists are required to advise patients with 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 temporary in nature. The chances of this happening are less than one in ten million. Tests, with or without x-rays, have been performed on you to minimize this risk to yourself. Chiropractic is considered to be one of the safest and most effective forms of therapy for neck conditions and other conditions.

·         I understand all accounts are payable when service is rendered.

  • Consent to all-encompassing chiropractic treatments knowing the Doctor(s) will discuss ahead of time with me. (Example: Orthotics, change of techniques, etc.)
  • Consent to seeing another Wilson Health Services Doctor if/when needed. (Example: time restrictions, scheduling, acute condition needing help or when my primary Doctor is away, etc.)
  •  I understand that to provide me with the health goods and services, Wilson Health Services will collect some personal information about me. (e.g. home telephone number, address, etc.)  

The privacy and protection of your personal information has always been an important part of our office. We are committed to collecting, using, and disclosing your personal information responsibly. All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us.  They are all trained in the appropriate uses and protection of your information. In this office, Dr. Jason Wilson acts as the privacy information officer. Along with this consent form, we have outlined what our office is doing to ensure that:

  • Only necessary information is collected about you
  • We only share your information with your consent
  • Storage, retention, and destruction of your personal information complies with existing legislation, and privacy protection protocols
  • Our privacy protocols comply with privacy legislation, standards of the regulatory body, the college of chiropractors of Ontario, and the law.
  • In the case of a missed appointment, our office has the right to call the phone number provided. 

By signing the consent section of this patient consent form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal information for the purposes that are listed. Please be assured that every staff person in our office is committed to ensuring that you receive the best quality care.

 

By clicking accept, I agree to Wilson Health Services collecting, using, and disclosing personal information about me as set above and in the Wilson Health Services’ Privacy Policy.

* Please read and agree to the terms
Signature
Today's Date: 21 Sep 2017