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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
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Conditions
COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
Willing to wash hands before entering clinic
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Willing to wash hands before 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 been tested for COVID?
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Have you had the antibody test?
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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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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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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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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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Been in group where social distancing not observed
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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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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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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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Staying the Same
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Tension
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Disabling
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Getting Better
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Discomfort
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Constant
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Imbalance
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Intermittent
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Increases with Activity
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Decreases with Activity
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No Change
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Other
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Allergy
Mastocytosis
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MCAD
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Medical
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Miscellaneous
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Coconut Oil
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Environmental
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Food
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Latex
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