Patient Intake Forms -

Patient Information (Please complete all fields below)

Motor Vehicle Accident please also complete the OCF 1 (Application for Accident Benefits):

https://www.fsrao.ca/ocf-1-application-accident-benefits

Work Place Injury please also complete the WSIB From 6(Worker's Report of Injury/Disease):

https://www.wsib.ca/sites/default/files/2021-04/0006a_workerreportofinjury.pdf

Last Name

First Name

Patient’s Email

Street Address

Home Tel .

City/Town

Province

Postal Code

Work Tel.

Date of Birth (mm/dd/yyyy)

Gender

Male

Female

Mobile Tel.

Name of Emergency Contact

Relationship

Emergency Contact Tel.

Name of Family Doctor

Family Doctor Tel.

Employer

Occupation

How did you hear about our clinic?

Answer

Return Patient

Location/Street Sign

Website

Answer

Family Doctor

Internet

Facebook/Twitter

Answer

Local businesses

Family/friend referral

Other

Main Street Health policies:

1. Please provide 24 hours notice of cancellation for your appointment. A $30 fee will be charged to your account if you do not show up for your appointment or if you choose to cancel within 24 hours of your appointment time.

2. Late arrivals will be seen for the remainder of their appointment time only or rescheduled for another day. It is our goal to stay on schedule to the best of our abilities.

I understand, and agree with, the criteria listed under Main Street Health policies

Signature of patient

Date

Consent to communicate via email

Can we email your appointment reminders to you 1 day prior to your appointment

Answer

Yes

I authorize Main Street Health to contact me via email/Text massage for appointment reminders and clinic information

Signature of patient

Date

Extended Health Benefits ( If applicable please complete all of the related information)

Insurance Company:

Certificate

Policy

Employee Name

Date of Birth

Employer Name

Employer Address

Have you registered for Online Billing?

Answer

Yes

Work Place Injury ( If applicable please complete all of the related information)

Date of Accident

Claim Number

Employer

Occupation

Phone

Fax

Do you have Extended Health Care Benefits?

Answer

Yes

(Please complete Extended Health Care section)

Motor Vehicle Accident ( If applicable please complete all of the related information)

Name of Automobile Insurance Company

Date of Accident

Policy Number

Claim Number

Have you reported your injuries to the insurance company?

Answer

Yes

Were you employed at the time of the accident?

Answer

Yes

Do you have a legal representative?

Answer

Yes

Name

(Please provide name)

Would you like us to refer you to a legal representative?

Answer

Yes

Do you have Extended Health Care Benefits?

Answer

Yes

(Please complete Extended Health Care section)

Current work status? (Please complete all of the related information)

Answer

Regular

Retired

Answer

Light Duty

Student

How Long?

Answer

Unemployed

Not working due to this problem

Disabled

Motor Vehicle Accident / Work place Injury - Accident Description (Please provide the following in the description)
1.How did the accident happen?
2.Did you go to the hospital?
3.What part of the body did you injure and feel pain in right away?

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Health History (Please complete all of the related information)

CARDIOVASCULAR

High blood pressure

Low blood pressure

Chronic congestive heart failure

Heart attack

Stroke/CVA

Chest pain

Phlebitis/varicose veins

Heart disease

Pacemaker or similar device(s)

OTHER CONDITIONS

Orthotics/arch supports

Osteoporosis/Osteopenia

Epilepsy

Depression

Allergies/hypersensitivity?

Digestive Conditions

Organ dysfunction

Dizziness

Urinary/bowel incontinence

HEAD/NECK

Ever been knocked unconscious?

History of headaches

History of migraines/ new onset?

Vision loss/changes

Dizziness/Double vision

Hearing loss/ear condition(s)

RESPIRATORY

Chronic cough

Shortness of breath

Bronchitis

Asthma

Emphysema

COMMUNICABLE DISEASES

Hepatitis

Skin conditions

HIV/AIDS

Any other communicable diseases or Haemophilia? If so, please describe:

Previous/Current Fractures:

Arthritis - Onset/type:

Diabetes Onset/type:

Cancer - Onset/type/current state:

Allergies/hypersensitivity?

Other:

Loss of sensation (area)

Is there a family history of any of the above conditions? if so, please describe:

Loss of sensation (area)

Primary complaint/injury at this time:

PELVIC HEALTH

Pregnant, Due date:

# of prior pregnancies:

# of children:

OF SPECIAL NOTE:

Please list any previous surgical procedures and any details/hardware (Ie/ prosthesis, wires, internal pins/fixators):

CURRENT MEDICATION(S)

(Please feel free to provide a copy of any . medication lists instead)

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