Dr. Allison Kivisto | 280 Edinborough Windsor, ON N8X 3C4 | Tel: 519.977.2225 | Fax: 519.977.

1542

CONFIDENTIAL PATIENT INFORMATION SHEET

PERSONAL HISTORY
Mr.

Mrs.

Miss.

Ms.

Dr.

Name: ______________________________________ Date of birth: ___ (MM)/___ (DD) /___ (YY) Age: ______ M / F
Address: __________________________ City: __________________ Postal code: _____________________________
Tel: Home _____________________ Business: ______________________ Cell: ________________________________
Occupation: ___________________________________ Email: ______________________________________________
Preferred method of communication: __________________________________ Leave Message?
Have you had a physical in the last year?

Yes No

Are you currently exercising?

Yes

No

Yes No

Do you train with a personal trainer? No Yes Name and location: __________________________________
How were you referred? _____________________________________________________________________________
Is this related to a motor vehicle accident (MVA)? Yes

No

Emergency Contact Name: _______________________ Tel: ____________________ Relationship: _________________

PREVIOUS MEDICAL EXPERIENCE

Name of Medical Doctor: __________________________________________ Tel: _______________________________
Previous Chiropractors name: ______________________________________ Tel: _______________________________
OHIP #: _______________________________________
Do you have extended health coverage?

Yes

No

Provider: _____________________________________

Have you received physiotherapy treatment before? Yes No Where: ________________________________

Have you received acupuncture before? Yes
Have you received massage therapy before?

No

Yes

No

Provider name: _________________________________

Where? ___________________________________

Do you give consent to allow Dr. Kivisto to contact your medical doctor? Yes

No

___________________________________
Parent/Guardian Name (Print)

___________________________________
Date

___________________________________
Parent/Guardian Signature

___________________________________
Witness (Dr. Kivisto)

Dr. Allison Kivisto | 280 Edinborough Windsor, ON N8X 3C4 | Tel: 519.977.2225 | Fax: 519.977.1542

CURRENT HEALTH HISTORY

Main Complaint: __________________________________________________________________________________
When did it start? ___________________________________________________________________________________
How did it start? ____________________________________________________________________________________
Is this a work related injury? Yes

No

Rate your pain (None)

10 (Excruciating)

Does the pain travel/move and if yes where? _____________________________________________________________

What is the pattern of this problem? Constant

Intermittent

Occasional

Cyclic

What makes the pain worse? (eg. Movement, time of day, stress) ____________________________________________
__________________________________________________________________________________________________
What makes the pain better? __________________________________________________________________________
Have you had this injury before? No

Yes When? _______________________________________________

Have you had previous treatment? No

Yes With who? ___________________________________________

Do you have pain that wakes you up at night? No

Yes

Have you recently lost or gained weight unintentionally? No

Yes

Do you have any additional complaints? _________________________________________________________________

Have you had previous treatment for your main complaint? Yes

No

If yes, please describe what did and did not work for you: ___________________________________________________
__________________________________________________________________________________________________
Which are aof life does this problem affect? Work

Family Activity/Sports

Everyday Life

Explain: ___________________________________________________________________________________________
What are your goals for treatment? (List 3) _______________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
How do you think chiropractic care will help you? _________________________________________________________
__________________________________________________________________________________________________

Dr. Allison Kivisto | 280 Edinborough Windsor, ON N8X 3C4 | Tel: 519.977.2225 | Fax: 519.977.1542

SYMPTOM DIAGRAM:
Please use the following chart to draw the letter X in
the areas that bother you. Beside each of these areas,
use the appropriate letter to describe what you feel.
(Example: if you hand is numb, draw an X in the hand
and put N next to the hand.
A Ache
B Burning
N Numbness
P Pain/soreness
S Stiffness
ST stabbing
T - tingling

PERSONAL MEDICAL HISTORY:

Do you currently suffer from or have you suffered in the past from any of the following? Please check any current issues
and mark and x for any past issues.
Allergies
Arthritis
Bleeding Disorders
Blood in urine
Blurred or double vision
Bowel/bladder issues
Bruise easily
Cancer
Chest pain
Chronic cough
Circulatory problems
Clumsiness
Concussions
Depression or anxiety
Diabetes
Difficulty breathing
Digestion issues

Dizziness
Eating disorder
Enlarged glands
Epilepsy
Excess hunger or thirst
Fainting
Fever
Fractures
Headahces
Hearing problems
Heart attack / Angina
Hemorrhoids
Hepatitis A/B/C
High blood pressure
HIV/AIDs
Hot flashes
Jaundice

Kidney issues
Loss of sleep
Loss of strength
Low bone density
Menstural issues
Nausea
Night sweats
Numbess or tingling
Painful ankle/foot
Painful arm /forearm
Painful hip
Painful knee
Painful shoulder
Painful wrist/hand
Problems speaking
Problems swallowing
Prostate trouble

Psychological disorders
Rashes / itching
Ringing in the hears
Sore/stiff low back
Sore / sitiff mid back
Sore / stiff neck
Sore / stiff tailbone
Spitting blood / phlegm
Stroke
Swelling of ankles /joints
Swollen lump in breast
Thyroid issues
Tremors
Varicose veins
Vision problems
Weak immune system
Weight loss/gain

Dr. Allison Kivisto | 280 Edinborough Windsor, ON N8X 3C4 | Tel: 519.977.2225 | Fax: 519.977.1542
List any medications, supplements (vitamins, etc.) are you currently taking:
1. ___________________________________________

5. ________________________________________

2. ___________________________________________

6. ________________________________________

3. ___________________________________________

7. ________________________________________

4. ___________________________________________

8. ________________________________________

List any medication conditions you have been diagnosed with (e.g. diabetes, heart disease, cancer, etc.)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Number of meals you eat per day: _______________

Are there any foods you avoid? ____________________

Do you wear orthotics? Yes No

If yes, how long have you and them? _______________

How many hours of sleep do you get per night? ______________

FAMILY HEALTH HISTORY

Have you or anyone in your family had any of the following (specify whom):
Heart Disease _________________________

High blood pressure ________________________

Cancer ______________________________

Diabetes _________________________________

Stroke ______________________________

Other ___________________________________

Women: Are you currently pregnant? Yes No

# Pregnancies: ________ # Children: _______

Are you on the birth control pill/patch? Yes No Previously

How long? ___________

PAST HEALTH HISTORY

List any previous Surgeries and the year(s) they occurred
______________________________ Year _________

_________________________________ Year ___________

List any previous Fractures and the year(s) they occurred

______________________________ Year _________

_________________________________ Year ___________

List any previous imaging (xray, MRI, CT etc.) and the year(s) they occurred
______________________________ Year _________

_________________________________ Year ___________

List any previous Accidents/Traumas and the year(s) they occurred

______________________________ Year _________

_________________________________ Year ___________

Are you currently a smoker? Yes No Previously

How much? ________________________________

Do you drink alcohol? Yes No How many drinks/week? _________________________________________

Dr. Allison Kivisto | 280 Edinborough Windsor, ON N8X 3C4 | Tel: 519.977.2225 | Fax: 519.977.1542
Describe your stress level at: Work _________ Personal Life __________ (0 = none, 10 = Extreme)
On a scale of Poor, Good, Excellent describe your: Exercise __________ Sleep _________ Diet _________
Is there anything else you would like us to know? __________________________________________________________
__________________________________________________________________________________________________

CONSENT TO EXAMINATION
All healthcare providers, including Doctors of Chiropractic, who conduct physical examinations require to advise patients
there are some risks associated with each examination. I understand and am informed that as in healthcare, a physical
examination is meant to provide the healthcare professional with the opportunity to obtain useful information about
individuals. The examination also allows the healthcare professional to establish relationships and to detect and address
problems in their earliest stages for beneficial results.
I further understand that there are some very slight risks to examination including but not limited to an aggravation of
symptoms or the need for further diagnostic testing. I understand that I will have the opportunity to discuss the details
of the examination with the healthcare professional and that I am able to discuss the nature and purpose of the
examination at any time as well as the contents of this consent.
I hereby consent to the examination offered or recommended to me by Dr. Allison Kivisto
___________________________________
Parent/Guardian Name (Print)

___________________________________
Date

___________________________________
Parent/Guardian Signature

___________________________________
Witness (Dr. Kivisto)

CONSENT FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION:

All personal information, including medical information, collected will remain safe and secured and will not be shared
with anyone without patient permission. The information may be collected via phone, personal interview, direct
examination, transfer of medical information from other healthcare professionals, and third parties including insurance
companies. Personal information will only be seen by Dr. Kivisto and registered healthcare providers at Midtown
Chiropractic. In the event where personal information is required by insurance companies, regulatory bodies and health
care professionals, verbal consent will be obtained before information is transferred. For further information on the
Personal Information Protection Electronic Document Act visit www.privcom.ca.
By signing this form, I hereby consent to the collection, use, and disclosure of my personal information
___________________________________
Parent/Guardian Name (Print)

___________________________________
Date

___________________________________
Parent/Guardian Signature

___________________________________
Witness (Dr. Kivisto)