Your Medical Record to Complete

General Informations

Last name :     First name :    

Birthdate : (dd//mm//yy)     Phone number :

Child    Student     Retired    Worker    Working type :

Working typel : Seated    Active   about  % seated    % standing     I walk a lot at work  

Appointment date at Marchildon (dd//mm//yy)

You are

Sedentary     Physically active (daily active)    

Do you exercise or practice any sports ?    Yes     No
   
If you do, what’s the exercise intensity

Moderate intensity     High intensity (sportive)     Maximal intensity (competitive) 

Specify which physical activities you practice in order of importance (ex.: walking, dancing, etc.) :

What is the main reason for visiting Marchildon's Laboratory ?

Pain    Discomfort  

Feet   Ankle   Leg    Knee    Hips    Back    Cervical    Other   

You worry about a change in your feet   You have a walking disorder

Please specify:

Do you suffer from physical pain (articular, muscular) ther than the main reason of your visit? 

Feet    Ankle   Leg    Knee    Hips    Back    Cervical    Other   

Please specify :

Do you suffer from a known health problem ?

Diabetes    Neuropathy   Rheumatoid Arthritis   Hypersensibility - sensory modulation disorder  

Raynaud disease   Circulatory problems    Fibromyalgia   

Medical referral

Do you have a medical referral (rx,prescription) ?  Yes No

If you do have a referral, where does it come from ?

Family doctor     Walk-in clinic doctor    Specialist doctor     Podiatrist     Chiropractor  

Health specialists

We send the medical report to all your multi disciplinary team

Please write your family doctor's name 
        
I don’t have any family doctor

Name of your family doctor :

If you have a specialist doctor, please indicate his/her name (rheumatologist, physiatrist, orthopedist, others) or any other healthcare professional (podiatrist, chiropractor, osteopath, physiotherapist, nurse, acupuncturist or others)          

I don’t have any specialist doctor or any other healthcare professional  

Name of the specialist doctor :

Speciality :        
 

Name ot the healthcare professional 1 :

Speciality :

Place of practice :

Name ot the healthcare professional 2 :

Speciality :

Place of practice :

References

Who referred you to Marchildon ?

The prescriber mentioned above    Other healthcare professional mentioned above   

or

A family member / friend / colleague (patient of ours)    

Name (if it's possible to mention) :

Website     From search on the internet    Publicity / Newspaper     Facebook     You live close by  

You have always known the reputation and fame of Marchildon

Other references    

Specify :

Do you take any medication ?

Against pain (pain-relief medication) ?    Yes   No    

Against inflammation (anti-inflammatory medication) ?    Yes     No    

Against a sensory or neuropathic disorder ?      Yes     No    

Surgery

Have you ever had a surgery for biomechanical, bone, joint or muscle problems  (ex.: hip prosthetis, knees) ?    Yes     No  

Please specify the surgery: