PATIENT INFORMATION:

Name: Mr., Mrs., Miss, Ms., Dr.____________________________________________________________

Address: ______________________________________________________________________________

City:______________________________________________ Postal Code: ________________________

Phone number: Home: ______________________________ Cell: ______________________________

Bus: ______________________________

Emergency contact name: ___________________________________ Phone: ______________________

Email Address __________________________________________________________________________

Date of Birth: ______/ ______/ ______ Age: __________ Gender: ____________

(mo.) (day) (yr.)

Occupation:____________________________________________________________________________

Marital Status: _____M _____S _____W _____D

Spouse’s Name: ______________________________________________ No. of children: ____________

Were your referred to this clinic? ______ Yes ______ No

If yes, by whom?________________________________________________________________________

If no, how did you hear about this clinic? ____________________________________________________

By providing my email address, I give consent to receive updates and information about Momentum Healing Arts Centre. Momentum Healing Arts Centre will never give out or sell any patient addresses.

Is your pain a result of a car or work accident? _______ yes _______ no

If yes, when was the accident: ____________________________________________Family Physician: ____________________________________________________________________Address: __________________________________________ Postal Code:______________________

Phone number: ____________________________________ Fax #: __________________________

T1065 CANADIAN PLACE, UNI #101MISSISSAUGA, ON

L4W 0C2

DR. ASTRID TRIM

DR. COLLEEN PRENDERGAST

H O LI S T I C H E AL I N G AR T SAncient Theory Modern Methods

1065 CANADIAN PLACE, UNIT #101MISSISSAUGA, ON

L4W 0C2

DR. ASTRID TRIM DR. PAUL RANKIN DR. TARA BROWN

PATIENT INFORMATION:Name: Mr., Mrs., Miss, Ms., Dr.____________________________________________________________

Address: ______________________________________________________________________________

City:______________________________________________ Postal Code: ________________________

Phone number: Home: ______________________________ Cell: ______________________________

Bus: ______________________________

Emergency contact name: ___________________________________ Phone: ______________________

Email Address __________________________________________________________________________

Date of Birth: ______/ ______/ ______ Age: __________ Gender: ____________ (mo.) (day) (yr.)

Occupation:____________________________________________________________________________

Marital Status: _____M _____S _____W _____D

Spouse’s Name: ______________________________________________ No. of children: ____________

Were your referred to this clinic? ______ Yes ______ No

If yes, by whom?________________________________________________________________________

If no, how did you hear about this clinic? ____________________________________________________

By providing my email address, I give consent to receive updates and information about Momentum Healing Arts Centre. Momentum Healing Arts Centre will never give out or sell any patient addresses.

Is your pain a result of a car or work accident? _______ yes _______ no

If yes, when was the accident: ____________________________________________

1

Family Physician: ____________________________________________________________________Address: __________________________________________ Postal Code:______________________

Phone number: ____________________________________ Fax #: __________________________

GENERAL HEALTH HISTORY: Please circle any condi ns or symptoms presently causing you problems. Please X those or symptoms which have been a health concern in the past.

GENERAL SYMPTOMS Blackouts

Headaches Migraines

Fever, Sweats ng

Dizziness Weight Loss

Loss of Sleep due to pain Convulsions

Numbness or Tingling in arms/legs Anxiety

Feelings of extreme stress

RESPIRATORYChronic cough

ng up phlegm or blood Chest pains

Shortness of breath

SKINRashes, eczema, itching

Bruising easily Dryness

Do you have any allergies? Yes No If so, to what ? ____________________

________________________________

MUSCLES & JOINTS Neck pain or ess

Mid back pain or Low back pain or Swollen & painful joints

Foot pain or injury Knee pain or injury

Shoulder pain or injury Arm/Forearm pain or injury

Wrist pain or injury Hand/finger pain or arthri s Weakness or loss of strength

Diagnosis of arthri s: What kind? __________________

EYES, EARS, NOSE, THROAT Blurry/double vision

Failing vision (one/both eyes) Eye pain

Deafness/Hearing loss Chronic earaches

Ringing/buzzing in one/both ears Asthma

Frequent colds/flus Sinus n

Enlarged lymph glands Enlarged thyroid

Abnormal thyroid on levels Slurred Speech

Difficulty swallowing

CARDIOVASCULARVaricose Veins

Swelling of the ankles Angina

Bleeding disorder High blood pressure Low blood pressure

High cholesterol Do you take medica on for these? Yes __________________ No ____

GASTROINTESTINALPoor appe

Indiges n Hiatus Hernia/Acid Reflux

Recurring Cons Chronic Diarrhea

Kidney Stones Gall bladder problems

Irritable Bowel Syndrome s /Crohns disease

Celiac disease Do you take medica on for

any of the above? Yes __ No __ If yes, what? __________________________

FOR WOMEN ONLYPainful menstr

Excessive flow Irregular cycle

Cramps or backaches History of breast cancer in family?

Yes ___________________ No _____ Are you menopausal?

Peri _____ Present _______Post _____ Are you on a Birth control pill?

Yes No Have you been diagnosed with osteoporosis

(low bone density)? Yes No

Number of pregnancies? ________ Number of children? ________

GENERAL QUESTIONS:

Have you ever been in a car accident? Yes No When? _____________________ Sleep Posture: circle all that apply: back stomach side Are you currently a smoker? Yes No Are you an ex-smoker? Yes No Do you take medica on on a regular basis? Yes No Please list your medica :

o For high blood pressure o For high cholesterol o For high/low thyroid o Blood thinners

_______________________ o Other medica :

_____________________ What is your current level of pain? x----------------------------------------------x 0 1 2 3 4 5 6 7 8 9 10 Please draw your pain on the figure:

H O LI S T I C H E AL I N G AR T SAncient Theory Modern Methods

1065 CANADIAN PLACE, UNIT #101MISSISSAUGA, ON

L4W 0C2

DR. ASTRID TRIM DR. PAUL RANKIN DR. TARA BROWN

PATIENT INFORMATION:Name: Mr., Mrs., Miss, Ms., Dr.____________________________________________________________

Address: ______________________________________________________________________________

City:______________________________________________ Postal Code: ________________________

Phone number: Home: ______________________________ Cell: ______________________________

Bus: ______________________________

Emergency contact name: ___________________________________ Phone: ______________________

Email Address __________________________________________________________________________

Date of Birth: ______/ ______/ ______ Age: __________ Gender: ____________ (mo.) (day) (yr.)

Occupation:____________________________________________________________________________

Marital Status: _____M _____S _____W _____D

Spouse’s Name: ______________________________________________ No. of children: ____________

Were your referred to this clinic? ______ Yes ______ No

If yes, by whom?________________________________________________________________________

If no, how did you hear about this clinic? ____________________________________________________

By providing my email address, I give consent to receive updates and information about Momentum Healing Arts Centre. Momentum Healing Arts Centre will never give out or sell any patient addresses.

Is your pain a result of a car or work accident? _______ yes _______ no

If yes, when was the accident: ____________________________________________

1

Family Physician: ____________________________________________________________________Address: __________________________________________ Postal Code:______________________

Phone number: ____________________________________ Fax #: __________________________

THE BOURNEMOUTH QUESTIONNAIRE

NAME__________________________ DATE_____________AGE_____Initials:______

The following scales have been designed to find out about your pain and how it is affecting you. Please answer ALL the scales by circling ONE number on EACH scale that best describes how you feel:

1. Over the past week, on average, how much would you rate your pain?No pain Worst pain possible0 1 2 3 4 5 6 7 8 9 10

2. Over the past week, how much has your pain interfered with your daily activities? (Housework, washing, dressing, walking, climbing stairs, getting in/out of bed/chair)No Pain Unable to carry out activity0 1 2 3 4 5 6 7 8 9 10

3. Over the past week, how much has your pain interfered with your ability to take part in recreational, social, and family activities?No pain Unable to carry out activity0 1 2 3 4 5 6 7 8 9 10

4. Over the past week, how anxious (tense, uptight, irritable, difficulty in concentrating/relaxing) have you been feeling?No Pain Extremely anxious0 1 2 3 4 5 6 7 8 9 10

5. Over the past week, how depressed (down in the dumps, sad, in low spirits, pessimistic, unhappy) have you been feeling?No pain Extremely depressed0 1 2 3 4 5 6 7 8 9 10

6. Over the past week, how have you felt your work (both inside and outside the home) has affected (or would affect) your pain?No pain Have made it much worse0 1 2 3 4 5 6 7 8 9 10

7. Over the past week, how much have been able to control (reduce/help) your pain on your own?No pain No control whatsoever0 1 2 3 4 5 6 7 8 9 10

---------------------------------------------------------------------------------------------------------------------------

OFFICE USE ONLY: SCORE_____/70 = _______%

H O LI S T I C H E AL I N G AR T SAncient Theory Modern Methods

1065 CANADIAN PLACE, UNIT #101MISSISSAUGA, ON

L4W 0C2

DR. ASTRID TRIM DR. PAUL RANKIN DR. TARA BROWN

PATIENT INFORMATION:Name: Mr., Mrs., Miss, Ms., Dr.____________________________________________________________

Address: ______________________________________________________________________________

City:______________________________________________ Postal Code: ________________________

Phone number: Home: ______________________________ Cell: ______________________________

Bus: ______________________________

Emergency contact name: ___________________________________ Phone: ______________________

Email Address __________________________________________________________________________

Date of Birth: ______/ ______/ ______ Age: __________ Gender: ____________ (mo.) (day) (yr.)

Occupation:____________________________________________________________________________

Marital Status: _____M _____S _____W _____D

Spouse’s Name: ______________________________________________ No. of children: ____________

Were your referred to this clinic? ______ Yes ______ No

If yes, by whom?________________________________________________________________________

If no, how did you hear about this clinic? ____________________________________________________

By providing my email address, I give consent to receive updates and information about Momentum Healing Arts Centre. Momentum Healing Arts Centre will never give out or sell any patient addresses.

Is your pain a result of a car or work accident? _______ yes _______ no

If yes, when was the accident: ____________________________________________

1

Family Physician: ____________________________________________________________________Address: __________________________________________ Postal Code:______________________

Phone number: ____________________________________ Fax #: __________________________

H O LI S T I C H E AL I N G AR T SAncient Theory Modern Methods

1065 CANADIAN PLACE, UNIT #101MISSISSAUGA, ON

L4W 0C2

DR. ASTRID TRIM DR. PAUL RANKIN DR. TARA BROWN

PATIENT INFORMATION:Name: Mr., Mrs., Miss, Ms., Dr.____________________________________________________________

Address: ______________________________________________________________________________

City:______________________________________________ Postal Code: ________________________

Phone number: Home: ______________________________ Cell: ______________________________

Bus: ______________________________

Emergency contact name: ___________________________________ Phone: ______________________

Email Address __________________________________________________________________________

Date of Birth: ______/ ______/ ______ Age: __________ Gender: ____________ (mo.) (day) (yr.)

Occupation:____________________________________________________________________________

Marital Status: _____M _____S _____W _____D

Spouse’s Name: ______________________________________________ No. of children: ____________

Were your referred to this clinic? ______ Yes ______ No

If yes, by whom?________________________________________________________________________

If no, how did you hear about this clinic? ____________________________________________________

By providing my email address, I give consent to receive updates and information about Momentum Healing Arts Centre. Momentum Healing Arts Centre will never give out or sell any patient addresses.

Is your pain a result of a car or work accident? _______ yes _______ no

If yes, when was the accident: ____________________________________________

1

Family Physician: ____________________________________________________________________Address: __________________________________________ Postal Code:______________________

Phone number: ____________________________________ Fax #: __________________________