NEW PATIENTS Please fill out our intake form below, and a member of our team will reach out to help you schedule your first appointment. Returning patient? Click Here to book a follow up appointment. AddressQEII Wellness Centre240 – 6845 66 StreetRed Deer, AB T4P 3T5 Phone(403) 887-0551 HoursCheck our Google Business Page for up to date hours here. INTAKE FORM Name * First Name Last Name Email * Phone * (###) ### #### Date of Birth mm/dd/yy * Address * City * Province * Postal Code * Country * Emergency Contact Info * Emergency Contact Name Relationship to you * Emergency Contact Home Phone Number * Emergency Contact Mobile Number * Family Physician Name * Family Physician Clinic Name * Family Physician Phone Number * Personal History * High Blood Pressure Stroke Osteoporosis Migraines None Other Family History * High Blood Pressure Stroke Osteoporosis Migraine None Check all that apply * Hospitalized in the past 5 years History of Cancer Unexplained weight loss Fevers Chills Change in bowel or bladder function Diabetes Smoking Alcohol, occasional Alcohol, more than 2/day Cortisone injection in the past 3 months None Do you exercise? * No Yes, occasionally Yes, moderately Yes, regularly List any past surgeries: * List any allergies, including latex: * Do you have any other diagnosed conditions not mentioned? * Area of concern: * Hand Wrist Foot Ankle Hip Knee Elbow Shoulder Back Side affected: * Right Left Both Can you explain your concern? * When did the pain start? * MM DD YYYY What do you attribute the pain to? If there has been a diagnosis, please provide as much information as possible: * How quickly to symptoms appear? * Sudden Gradual Chronic Does the pain radiate? * No Yes, into left arm Yes, into right arm Yes, into left leg Yes, into right leg How does the pain feel? Dull Sharp Electric Tingling What makes the pain worse? How long does the pain last? * Check any of the following that reduce pain: * Rest Ice Heat Pain Relievers Exercise None Of The Above Treatment History * Check any medications you are taking: Advil Aleve Ibuprofen Motrin Aspirin Statin (for high cholesterol) Blood Thinners None of the above Please list any medications not listed above: * Any treatments you have previously tried? * Chiropractor Physiotherapy Massage Heat Ice Bracing Tylenol Muscle Relaxants Cortisone Injections Steroid Injections Anti-inflammatories Prescription medication Viscosupplementation Migraine Medication Spinal Decompression Acupuncture None of the above Previous Diagnostics: * Ultrasound X-Ray CT Scan MRI Bone Scan None I have answered the questions above and read and understand the following: * Payment Policy Pre-treatment Guidelines Which of the following refers to you: * I am an Albertan and my imaging reports are available on Netcare I am not an Albertan and have faxed my imaging reports to (855) 878-9273 Thank you!
