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