Box 1570, 212 2nd Ave West Brooks, AB T1R 1C4

Ph: 403-793-8484 Fax: 403-793-8483

________________________________________________________________________________________

Dear Patient,

Thank you for choosing Soft Health and Healing Clinic as your health care provider for your Worker’s Compensation

Board (WCB) claim. We look forward to providing you with top notch, state-of-the-art care.

There are a few things you must accomplish before beginning treatment at Soft Health and Healing Clinic:

1. You must report the injury as soon as possible to your employer. He/she will send an “Employer Report of Injury”

form to WCB within 72 hours.

2. You must also see your family physician regarding your injury. He/she will complete a “Physician’s Injury Report”

and send it to WCB within 48 hours.

3. Complete a “Worker’s Report of Injury” if you have a permanent injury, need medical treatment or are off work. Send

your report to the WCB.

WCB will register your compensation benefits upon receiving all of these reports. You will then have a representative

assigned to your claim. Please make sure that the information you provide is as detailed and complete as possible as this

will help for a timely decision on your claim.

In order to receive treatment at Soft Health and Healing Clinic you will be required to sign a WCB contract explaining

that you are responsible for the costs of your treatments should the WCB deny your claim.

Coverage through WCB entitles you to one treatment per day, up to a twenty-two (22) treatment maximum, over a 6 week

period. A soft tissue session counts as one (1) treatment, and a low intensity laser therapy session also counts as one (1)

treatment. We will contact the WCB requesting more care if the Doctor feels it is necessary.

Please read through the information provided and fill out all attached questionnaires. Remember that the more

information we have, the better we can diagnose and treat your condition. Please make sure to note anything you have

noticed leading up to and/or after the injury, no matter how insignificant it may seem.

Yours in Health,

Soft Health and Healing Clinic

Worker’s Compensation Board – Intake Forms

Personal Information:

First Name __________________ Middle Initial _____ Last Name ______________________

Alberta Health Care # ________________ Date of Birth _______________ Male / Female

Address ___________________________ City ___________________ Province _____

Postal Code ________________ E-mail ________________________

Ph# (home) ________________ Ph# (work) _______________ Ph# (cell) ________________

WCB Claim # _________________ Claims Rep. Name _________________ Ph# ____________

Work information:

Job Title: ________________________________________

Employer Name: _______________________________________________________________

Company Ph: ( ) _______________________________ Ext. _________

Address: ______________________________________________________________________

City: _______________________ Province: _________ Postal Code: ______________________

Injury Information:

Date of Injury (YYYY/MM/DD): _____________ Date of First Treatment (YYYY/MM/DD): ____________

Describe, fully, what you believe caused your condition. Please include any relevant past history.

____________________________________________________________________________________

____________________________________________________________________________________

_________________________________________________________________________________

Area(s) of Injury/Disease:

O Ankle O Arm O Back O Brain O Elbow O Face O Fingers

O Foot O Hand O Head O Knee O Leg O Non-personal O Shoulder

O Systems O Teeth O Trunk O Unknown O Wrist

Side of the Body: O Right O Left O Both Sides

Have you had the same or similar complaint before?

O Never O 2 times O 4 times O Multiple times O 1 time O 3 times O > 4 times

Has the problem been getting better or worse since the onset?

O Improving O Getting worse O Comes and goes O Stayed about the same

What limitations have you experienced as a result of your injury? (choose all that apply and

circle capabilities)

O Sitting Able Unable Limited to ___ O Climbing Able Unable Limited to ___

O Standing Able Unable Limited to ___ O Pushing/Pulling Able Unable Limited to ___

O Walking Able Unable Limited to ___ O Overhead reaching Able Unable Limited to ___

O Bending Able Unable Limited to ___ O Driving Able Unable Limited to ___

O Twisting Able Unable Limited to ___ O Lifting Able Unable Limited to ___

O Kneeling/squatting Able Unable Limited to ___

Describe how this injury affects your job requirements:

____________________________________________________________________________________

____________________________________________________________________________________

_________________________________________________________________________________

Have you missed any work as a result of your condition?

O Yes - If yes, how many days did you miss? __________ days. O No

Have you returned to work? O Yes O No

Current work status: O Yes – full duties O Yes – modified duties

O Yes – alternate duties O No – not working at all

Is modified work available? O Yes – it is available and I can perform the required tasks

O Yes – it is available but I cannot perform the required tasks O No – it is not available/possible

Are you working Modified hours? O Yes O No

If not working do you have a job to return to? O Yes O No

Your last full day of work was (YYYY/MM/DD)? ______________________

Are you currently receiving worker’s compensation? O Yes O No

List your surgical and hospitalisation history.

Past Surgical History

Date: ____________________

Where: _______________________________

Type of Surgery: ________________________

Surgeon: ______________________________

Complications/remaining problems:

______________________________________

Past Hospitalisations

Date: ______________________

Cause of Hospitalisation: __________________

___________________________________________

___________________________________________

Complications/remaining problems:

______________________________________

List your previous medical treatment and diagnostic tests. For example: Plain X-rays / CT Scan / MRI / EMG / Myelogram / Discogram / Thermogram / Bone Scan / Blood & Urine Chemistries / Other

Type of Test:

Date (approx):

Hospital/facility name:

Area of Body:

List your current medications, both prescription and non-prescription:

1. ______________________________ 4. ______________________________

2. ______________________________ 5. ______________________________

3. ______________________________ 6. ______________________________

Health History Questionnaire

Have you ever been diagnosed or told you have any of the following: Circle the correct response.

1. High Blood Pressure? Yes/No

2. Hardening of the arteries (arteriosclerosis)? Yes/No

3. Diabetes? Yes/No

4. Tuberculosis? Yes/No

5. Cancer? Yes/No

6. Heart or blood diseases? Yes/No

7. Bone spurs on the neck? Yes/No

8. Whiplash injury? Yes/No

9. Have you or any of your relatives ever suffered a stroke? Yes/No

10. Were you ever a Smoker? Yes/No

From _________________________ To _______________________ 11. Do you take medication on a regular basis? Yes/No

12. Visual disturbances (blurring, loss, double vision)? Yes/No

13. Hearing disturbances (loss, ringing, other noise)? Yes/No

14. Slurred speech or other speech problems? Yes/No

15. Difficulty swallowing? Yes/No

16. Dizziness? Yes/No

17. Loss of consciousness, even momentary blackouts? Yes/No

18. Numbness, loss of sensation, loss of strength or weakness in the face, fingers, hands, arms, legs, or any other

parts of the body? Yes/No

19. Sudden collapse without loss of consciousness? Yes/No

20. Back pain/Leg Pain Yes/No

21. Neck pain/Arm Pain Yes/No

22. Depression, Anxiety, etc. Yes/No

23. Recent international travel Yes/No

Please explain any “Yes” answers above:

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Systems Review

Circle any conditions that are presently causing you a problem. Underline those that have caused you problems in the past.

GENERAL SYMPTOMS RESPIRATORY GENITOURINARY

Fever Sweats Fainting Sleep disturbance Fatigue Nervousness Weight loss Weight gain

Chronic cough Spitting up phlegm Spitting up blood Chest pain Wheezing Difficulty breathing Asthma

Frequent urination Painful urination Blood in urine Pus in urine Kidney infection Prostate trouble Uncontrollable urine flow

NEUROLOGICAL CARDIOVASCULAR GASTROINTESTINAL

Visual disturbance Dizziness Fainting Convulsions Headache Numbness Neuralgia (nerve pain) Poor coordination Weakness

Rapid beating heart Slow beating heart High blood pressure Low blood pressure Pain over heart Hardening of arteries Swollen ankles Poor circulation Palpitations Cold hand or feet Varicose veins

Poor appetite Difficult digestion Heartburn Ulcers Nausea Vomiting Constipation Diarrhea Blood in stool Gallbladder/jaundice Colitis

EYES, EARS, NOSE, THROAT MUSCLE & JOINT FOR WOMEN ONLY

Eye pain Double vision Ringing in ears Deafness Nosebleeds Trouble swallowing Hoarseness Sinus infection Nasal drainage Enlarged glands

Neck pain Low back pain Arm pain Shoulder pain Leg pain Knee pain Foot pain Pain/numbness down arms or legs Pain between shoulders swollen joints Spinal curvature Arthritis Fractures

Painful menstruation Hot flashes Irregular cycle Cramps or back pain Vaginal discharge Nipple discharge Lumps in breast Menopausal symptoms Birth control pills Miscarriages Complications with pregnancy Pregnant? Y / N Week? Other:

Pain Drawing

Activities Discomfort Scale

Box 1570, 212 2

nd Ave West

Brooks, AB T1R 1C4

Ph: 403-793-8484 Fax: 403-793-8483

_____________________________________________________________________________________

Worker’s Compensation Board Contractual Agreement

1. I understand that Soft Health and Healing Clinic has agreed to provide chiropractic services

and will not require payment until my claim has been approved by WCB, after which time Soft Health and Healing Clinic will bill WCB directly.

2. I understand that if I am not approved by the WCB, that I am liable for any and all charges

incurred for services provided to me by Soft Health and Healing Clinic

3. In the event that the WCB denies my approval after already having approved it, I understand that I will be responsible for payment of fees from the date of denial forward.

4. I understand that Soft Health and Healing Clinic has a cancellation policy in place, wherein

any appointment missed or cancelled within 24 hours is subject to a cancellation fee equal to the treatment fee. I further understand that I, not WCB, am responsible for payment of any cancellation fees.

5. I understand that if I cancel or fail to show up for three consecutive appointments (without

explanation within twenty four [24] hours) that Soft Health and Healing Clinic will automatically suspend my treatments and notify my case worker. Soft Health and Healing Clinic will not arrange extra treatments to make up for such absences.

6. I understand that my initial treatment protocol period is six (6) consecutive calendar weeks

with a maximum of twenty two (22) treatments available and that only one (1) treatment can be performed and billed to WCB per day.

_____________________________ __________________________________ Patient Name (Printed) Patient Signature _____________________________ __________________________________ Date Witness to Above Signature

Visa MC Amex _ _____________________________ Credit Card # Expiry

Cancellation Policy

Purpose

The purpose of this policy is to encourage awareness that missed appointments have an impact on the

physician’s, therapists’ and patients’ schedules. Arranging appointments according to prescribed treatment

plans assists both patient and practitioner in achieving optimal healing goals in a quicker timeframe.

Policy

Soft Health and Healing Clinic requires 24 hours notice if an appointment is to be missed. Less than 24 hours notice will result in a cancellation fee of $40.

Thank you for your understanding.

THE “50% RULE”

The chiropractic physician is seeking 50% relief of pain (measured subjectively and objectively)

within 30 days of care.

TYPICAL PATIENT OUTCOMES

Median number of days to maximum improvement: 29

Median number of visits to maximum improvement: 12

OFFICE USE ONLY

Claim #: AHC#:

Adjustor’s Name:

Adjustor’s Phone#:

Date of Injury:

Exam Date:

Chiropractic First Report Submission Date:

Progress Report Date:

Treatment Extension Request Date:

Discharge Date:

Notes: