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
Gender
Date of Birth
Height
Weight

Parent/Guardian

First Name
Last Name
Home Phone
Email
Cell Phone
How did you hear about us?
Skywalk Health Inc.
211-393 Portage Ave
Winnipeg, MB R3B 3H6
(204) 505-7007
hello@skywalkhealth.ca
Complications during pregnancy?
Ultrasounds during pregnancy?
Medications during pregnancy?
Cigarette/alcohol use during pregnancy?
Location of birth:
Birth intervention performed:
Delivery medication?
Delivery complications?
Birth Weight
APGAR Scores
Birth Length
Skywalk Health Inc.
211-393 Portage Ave
Winnipeg, MB R3B 3H6
(204) 505-7007
hello@skywalkhealth.ca
Name of Pediatrician
Date of Last Visit
Reason
Treatment
At what age, in months, was the following introduced?
Solids:
Cows milk:
At what age was your child able to (in months):
Respond to sound
Hold head up
Crawl
Sit



Respond to visual stimuli
Stand Alone
Walk Alone


Personal Illness History
Skywalk Health Inc.
211-393 Portage Ave
Winnipeg, MB R3B 3H6
(204) 505-7007
hello@skywalkhealth.ca
Vaccination history
Family history
Please list any vitamins, herbs, or minerals the child takes:
Childhood Diseases
Skywalk Health Inc.
211-393 Portage Ave
Winnipeg, MB R3B 3H6
(204) 505-7007
hello@skywalkhealth.ca
Number of doses of antibiotics your child has taken:
Last 6 months: Since birth:
Number of doses of other prescription medications your child has taken:
Last 6 months: Since birth:
Child's daily habits (skip any questions that do not apply):
Hours of sleep per night (1-24)
Child's exercise
Average amount of time spent watching TV, playing video games, or using a computer per day:
How often does this child consume:
Caffeine Drinks:
Sugars/sweets:
Dairy Products
Wheat Products
Fruits/Vegetables
Water as a beverage:

Skywalk Health Inc.
211-393 Portage Ave
Winnipeg, MB R3B 3H6
(204) 505-7007
hello@skywalkhealth.ca
Present problem:
First occurrence of condition
Did something specific cause this condition? (please describe)
Since the problem started, is it:
Does anything make it better?
Does anything make it worse?
Other health professionals seen for this problem (please list names and dates if applicable)
Chiropractor
Medical Doctor
Other
Skywalk Health Inc.
211-393 Portage Ave
Winnipeg, MB R3B 3H6
(204) 505-7007
hello@skywalkhealth.ca
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 Insurace

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
Relationship to patient
Signature
Today's Date: 22 Oct 2019