On The Move Chiropractic
Health History
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Emergency Contact
Emergency Contact
Emergency Phone
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Doctor
Doctor's Name
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Medical Info
Primary Complaint
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General Health
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Current Treatment
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Past Treatment (from other practitioners)
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Medications
Injuries
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Additional Info
Insurance Info
Insurer's Name
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Adjuster's Name
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Office Address
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Phone
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Fax
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Email Address
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Claims / Benefit
Conditions
Health Questions
Diabetes
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Low blood pressure
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Stroke
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Epilepsy
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Meniere Disease
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Varicose veins
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Asthma
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Gastrointestinal
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Migraines/Headaches
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Vertigo
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Blood thinner medication
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Hearing Impairment
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Mood Disorder
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Warts
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Cancer
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Heart Attack
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Pacemaker
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Cardiovascular
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Concussion
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Heart Condition
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Past Heart Surgery
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Congenital Heart Defect
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High blood pressure
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Schizophrenia
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Depression
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HIV/Aids
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Well Being
Flexibility
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Sugar Intake
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Hobbies
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Supplements
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Interests
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Water Intake
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Mobility/Walking Aids
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Range of Motion
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Caffeine
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Salt Intake
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Drinking
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Smoking
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Exercise
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Sports
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Have you ever seen a Naturopathic Doctor before?
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Are you currently taking any supplements/Natraceuticals?
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How often have you taken antibiotics in the last 2 years?
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Energy Level
Fatigue
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Flat
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High
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Agitated
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Low
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Chaotic
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Vibrant
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Clear
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Dull
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Even
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Feet
Plantar Fasciitis
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Bunions
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Pes Cavus (High Arch)
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Pes Planus (Flat Feet)
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Treatment Goals
Pain Relief
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Rehabilitation
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Stress Relief
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Support in Healing/Recovery
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Health Advice for Healing
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Improve Lifestyle
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Improve Symptoms
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Improve Well Being
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Other
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COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
Changes to your medical history since initial intake?
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Willing to wash hands before entering clinic
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Willing to wash hands before leaving clinic
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Willing to sanitise hands when entering and leaving clinic
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Willing to wear face mask in the clinic
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Agree to wear face mask during treatment
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Have you taken precautions to limit exposure
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Have you tested positive for COVID-19?
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Have you been tested for COVID?
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Have you had the antibody test?
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Have you been vaccinated?
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Fever Over 100.4 degrees
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Fever Over 38 degrees
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Headaches
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What is your Temperature?
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New Onset of Cough
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Worsening Chronic Cough
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Sore Throat
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Difficulty Swallowing
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Shortness of Breath
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Difficulty Breathing
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Persistent Pain in Chest
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Decrease or sudden loss of taste and smell
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Have you had a new onset of muscle aches and pain since the emergence of the virus?
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Unexplained Fatigue/Malaise/Muscle Aches (Myalgia)
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Fatigue
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Chills
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If a child, purple markings on fingers and toes
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Pink eye (conjunctivitis)
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Nasal or sinus congestion
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Runny nose/nasal congestion without other known cause
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Nausea
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Vomiting
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Diarrhea
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Abdominal Pain
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Sudden onset body aches
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New rash or other skin changes
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Have you seen any new marks, rashes, spots, bumps, or other lesions on your skin?
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Regular cardio exercise
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Can you exercise to get your heart rate up without any problem?
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Can you exercise to get your respiratory rate up without any problem?
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Contact with someone with COVID
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Had close contact with a confirmed case of COVID-19 without wearing PPE
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Are you in high or moderate risk groups?
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Have you been shielding?
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Contact with someone who is awaiting COVID test results.
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Contact with someone who was in contact with COVID
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Contact with anyone with acute respiratory Illness
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Recent domestic air travel
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Recent international air travel
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Recent travel to area with high infection rates
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Recent travel outside your province within the past 14 days
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Did you travel outside of Canada in the past 14 days?
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In the past 2 weeks, have you or someone with whom you interact traveled outside the Atlantic Bubble?
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In the past 2 weeks, have you or someone with whom you interact traveled outside of Nova Scotia?
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In the past 2 weeks, have you or someone with whom you interact traveled to or from Halifax Regional Municipality?
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To the best of your knowledge, within the last 14 days has any member of your household or support bubble tested positive for COVID-19 or experienced any COVID-19 symptoms?
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To the best of your knowledge, within the last 14 days have you or any other member of your household or support bubble has been exposed to anyone diagnosed with COVID-19 or experiencing COVID?
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Within the last 14 days, have you tested positive for COVID-19 or experienced any COVID-19 symptoms?
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Have you travelled abroad in the last 14 days?
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Have you received a covid alert that you were in close contact with someone with covid, through the covid app in the last 14 days?
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Been in group where social distancing not observed
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Are you required to be self-isolating for any reason?
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Is anyone else in your household or that you've had close contact with experiencing any cold, flu or stomach virus like symptoms?
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Are you considered high risk?
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Spend time around anyone that is high risk
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If over 70, unexplained or increase number of falls?
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If over 70, acute functional decline?
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If over 70, worsening of chronic conditions?
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If over 70, symptoms of delirium?
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I agree to wear a clean disposable or reusable mask
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I agree to wash/sanitize my hands before and after treatment
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No COVID Symptoms
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Do you consent to me informing NHS Scotland Test & Protect of your details if either you or I find out we are infected?
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Do you consent to the consultation, assessment and treatment by the therapist?
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Area of Complaint
Neck
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Left Side of Neck
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Right Side of Neck
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Upper Back
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Left Side of Upper Back
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Right Side of Upper Back
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Mid Back
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Left Side of Mid Back
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Right Side of Mid Back
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Low Back
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Left Side of Low Back
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Right Side of Low Back
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Chest
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Abdomen
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Left Arm
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Right Arm
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Left Shoulder
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Right Shoulder
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Left Elbow
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Right Elbow
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Left Wrist
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Right Wrist
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Left Hand
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Right Hand
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Left Leg
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Left Thigh
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Left Calf
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Right Leg
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Right Thigh
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Right Calf
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Left Gluteal
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Right Gluteal
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Left Hip
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Right Hip
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Left Groin
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Right Groin
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Left Knee
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Right Knee
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Left Ankle
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Right Ankle
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Left Foot
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Right Foot
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Sacrum
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Tailbone (coccyx)
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Headaches
Headaches
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Migraines
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Rebound
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Sinus
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Tension
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Chronic Daily Headache
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Cluster
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Other Headaches
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Brain Disorders
Anxiety
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Depression
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PTSD
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Other Psychological
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Neurological
Cerebral Palsy
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Epilepsy
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Parkinsons
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Stabbing
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Stroke
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Cerebral Vascular Accident (Stroke)
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Fatigue
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Peripheral Neuropathy
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Syringomyelia
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Cerebral-vascular Accident
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Fibromyalgia
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Post Polio Syndrome
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Tethered Cord
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Cerebrospinal Fluid Leak
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Herniated Disc
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Sciatic Pain
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Bell's Palsy
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Tingling
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Chiari Malformation
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Huntington Disease
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Seizure Disorder
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Brain Disorder
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Brain Injury
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Transient Ischemic Attacks (TIA)
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Chronic Pain Disorder
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Loss of Sensation
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Shingles
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Burning
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Twitching of Face
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Dizziness
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Multiple Sclerosis
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Shingles / Herpes
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Carpal Tunnel
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Vertebral and Spinal Cord Injury
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Dural Ectasia
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Numbness
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Sleeping Disorders
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Other Neurological
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Musculoskeletal
Osgood-Schlatter Disease
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Arthritis
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Scleroderma
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Chronic Fatigue Syndrome
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Torticollis
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Fracture
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Gout
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Osteoarthritis
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Artificial Joints / Special Equipment
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Scoliosis
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Chronic Myofascial Pain Syndrome
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Whiplash
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Hereditary/Congenital Deformity
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Osteomalacia
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Baker's Cyst
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Sinus Problems
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Compartment Syndrome
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Jaw Pain (TMJD)
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Osteoporosis
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Bone Disease
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Spasms / Cramps
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Degenerative Disk Disease
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Joint Injury
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Paget Disease
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Bone or Joint Disease
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Spondylolisthesis
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Dislocation
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Joint Stiffness / Swelling
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Adhesive Capsulitis
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Plantar Fasciitis
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Broken Bone / Fracture
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Strain/Sprain
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Dupuytren's Contracture
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Muscular Dystrophy
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Amyotrophic Lateral Sclerosis (ALS)
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Psoriatic Arthritis
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Carpal Tunnel Syndrome
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Temporomandibular Joint Dysfunction
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Ehlers-Danlos Syndrome
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Myasthenia Gravis
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Ankylosing Spondylitis
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Recti Diastasis
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Tendonitis/Bursitis
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Fibromyalgia
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Other Musculoskeletal
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Family History
Cardiovascular
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Diabetes
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Respiratory
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Arthritis
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Cancer
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General Injury Related Questions
What is the next competition/challenge?
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Previous sports-related injuries?
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Treatment of previous injury?
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Physical Therapy
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Chiropractic
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Have you ever had CranioSacral treatment before?
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OTC medications
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Pain medications or steroids
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Surgery (type/year)
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Complications from that injury?
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Miscellaneous
Hearing Impaired
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Loss of Balance
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Vision Problems
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Other Medical Conditions
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Other Diagnosed Diseases
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Which best describes what you are experiencing
Pain
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Mild
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Getting Worse
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Ache
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Moderate
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0
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Staying the Same
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0
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Tension
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0
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Disabling
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0
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Getting Better
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0
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Discomfort
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0
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Constant
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0
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Imbalance
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0
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Intermittent
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0
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Increases with Activity
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0
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Decreases with Activity
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No Change
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0
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Other
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Current Complaint
Pain Severity: 1-10
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Date of Injury?
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Prescription pain meds Did it help?
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Steroids (oral) Did it help?
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Steroids (injection) Did it help?
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Heat Did it help?
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0
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Cold Did it help?
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0
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Immobilization Did it help?
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0
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Other creams, gels or unguents
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0
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Other therapies
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0
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Physical Activities You Participate In
Lacrosse
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0
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Tennis
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0
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Baseball
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Marathon
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Triathlon
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0
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Basketball
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0
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Pilates
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0
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Waterpolo
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0
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Crossfit
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0
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Rugby
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0
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Weight Lifting
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0
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Football
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0
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Running
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0
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Yoga
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0
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Golf
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0
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Soccer
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0
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Hockey
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Softball
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Swimming
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Other Activities
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Number of Times of Week You Practice
Once a week
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2-4 times a week
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More than 4 times a week
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Less than a couple of times a month
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