Chiropractic Treatments · Health Insurance/Payment: Many insurance companies have benefits...
Transcript of Chiropractic Treatments · Health Insurance/Payment: Many insurance companies have benefits...
Chiropractic Treatments
Consultation/Examination with Treatment $85.00
Chiropractic Subsequent Visit $45.00*
Reassessment
Acupuncture Visit
Concussion-Baseline/Re-Evaluation
$70.00
$55.00*
$80.00
Concussion Treatment
Custom Orthotics
$55.00
$500.00
*$5.00 Student & 65+ Seniors’ Discount on select
services
Registered Massage Therapy (HST incl.)
30 Minute $60.00
45 Minute $75.00
60 Minute $90.00
90 Minute $130.00
Missed Appointment and Cancellation Policy If you are unable to keep a scheduled appointment, please give 24 hours advance notice,
to ensure that you will not be charged for the appointment.
If less than 24 hours noticed is given, you will be expected to pay for the appointment.
Health Insurance/Payment: Many insurance companies have benefits covering all or part of your chiropractic and/or
massage care. It is best to check your coverage to determine if you have these benefits. Direct billing is available for
some companies and some policies. Payment for the cash portion of your bill is expected the day of treatment.
Dr. Cameron Read & Dr. Mallory Kohlmeier
2795 Princess Street, Kingston, ON., K7P 2X1
Patient Profile
Date: __________________________________ Date of Birth: (D) ______ (M) ______ (Y)_____________
Name: _________________________________ Home or Cell Phone: _____________________________
Address: _______________________________ Work Phone: ___________________________________
City: ___________________________________ email: _________________________________________
Postal Code: ____________________________ Age: ___________________________________________
Height: _______________ Weight: ______________
Occupation: ____________________________ Gender: _______________
Have you seen a chiropractor before? _____Yes _ __No
Were you referred to our office? _____Yes ______ No If yes, whom may we thank? _____________________
Would you like to receive by email: appointment reminders: _______ newsletter: _______ exercises: _________
Primary Symptom(s):
Where? ______________________________________________________________________________________
How long? ____________________________________________________________________________________
How did it begin? ______________________________________________________________________________
What aggravates it? ____________________________________________________________________________
What relieves it? ______________________________________________________________________________
Which of the following apply?: _____ It’s getting better. ______It’s getting worse. ______It’s the same.
Any treatments given:___________________________________________________________________________
Any recent weight loss? ________Y _________N
I, ___________________________________ authorize Frontenac Chiropractic and Sports Rehab to contact
my physician; Dr. ______________________________________on my behalf.
Phone Number: ____________________________
Signature: _____________________________________ Date: _________________________________________
Health Status Survey
Patient Name: File#: Date:
Please X the options which apply to your current symptoms and condition(s)
Please ✓ the option which represent symptoms or condition you have had in the past
General Symptoms o Loss of Consciousness o Blackouts o Headaches o Fever o Excess Sweating o Night Sweats o Loss of Weight o Night Pain o Generalized Pain o Nervousness o Convulsions o Loss of Sleep
Neurologic o Dizziness o Fainting o Problem Speaking o Blurred Vision o Problem Swallowing o Nausea o Clumsiness o Numbness/Tingling o Double Vision
Muscles and Joints o Sore/Stiff Neck o Mid Back Pain o Low Back Pain o Painful Tailbone o Shoulder Pain o Arm/Forearm Pain o Elbow Pain o Wrist/Hand Pain o Hip Pain o Knee Pain o Arthritis o Loss of Strength
Eyes/Ears/Nose/Throat o Failing Vision o Eye Pain o Failing Hearing o Ring/Buzz in Ears o Frequent Colds o Sinus Infection o Enlarged thyroid o Enlarged Glands
Respiratory o Asthma o Chronic Cough o Spitting up Phlegm o Spitting up Blood o Difficulty Breathing
Cardiovascular o Bleeding o High Blood Pressure o Chest Pain o Stroke o Hardening of Arteries o Varicose Veins o Swelling of Ankles o Poor Circulation o Heart/Blood Disease o Angina
Genitourinary o Trouble Urinating o Blood in Urine o Kidney Infection o Bedwetting o Prostate Trouble
GU for Women o Painful Menstruation o Excess Flow o Irregular/Absent Cycle o Hot Flashes o Cramping/Backache o Vaginal Discharge o Swollen Breasts o Lump in Breasts
Currently on Birth Control pill/patch? o Yes o No
Previously on Birth Control pill/patch? o Yes o No
# of Pregnancies: # of Children: Medication List:
Skin o Rashes/Itching o Bruising easy o Dryness o Boils o Hives (allergies)
Gastrointestinal o Vomiting o Poor Appetite o Indigestion o Excess Hunger o Belching of gas o Pain Over Stomach o Constipation o Diarrhea o Hemorrhoids o Jaundice o Gall Bladder Trouble o Intestinal Worms o Ulcer o Diabetes
Have you ever been in a car accident? o Yes o No
If so, when Have you ever had any fractures?
o Yes o No
If so, where? Have you ever been hospitalized?
o Yes Why/When? o No
Why/When? Do you smoke?
o Yes-How much? o No
Did you smoke previously? o Yes-How much? o No
Have you ever been diagnosed with: o HIV o Cancer o Hepatitis A/B/C