240 Richmond Street, London, Ontario | Phone: 519-850-4721 | Fax: (519) 850-1816

Health Screening Form

Custom Orthotics of London > Health Screening Form

Fill out our Intake Cranial Form below. Or feel free to print and fill these out in advance and bring to your initial appointment or email it to [email protected].

Click to Print or Download Form

    Client Name (required)

    Reason for Visit: (required)

    History of Present Illness: (required)

    Past Medical History (required)
    Heart Problems Hepatitis A or BVision Problems Pacemaker/DefibrillatorHypertension Hepatitis C Parkinson Disease Seizure DisorderVascular DiseaseHIV Positive Alzheimer Disease Hearing LossStroke Rheumatoid Arthritis MRSA Currently PregnantDiabetesObesityKidney Disease Psychiatric ProblemsOsteoarthritis Alcoholism Osteoporosis Pulmonary Disease (TB)Other:

    Previous Surgeries/Orthotic Care: (required)

    ADLs, Recreational Activities: (required)

    Living Status:
    Alone/Without Assistance Home with AssistanceLong Term Care Facility

    Treatment Past and Current: (required)

    Pain Level (0 - No pain, 5 Moderate, 10 Worst pain possible)

    Additional Comments

    Resources

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