As per our discussion over the phone, prior to your appointment please complete this intake form to allow us to better establish your treatment plan before you arrive.Please enable JavaScript in your browser to complete this form.Client Name *FirstLastIf you have an appointment booked with us already, which location is it at?Red Deer Main (Downtown)OldsRed Deer CampusAppointment Not BookedPhone *EmailWhat areas/body parts were injured or are bothering you as a result of your motor vehicle accident that you want cared for?Have you ever been hospitalized or had medical imaging done for a head injury (CT or MRI)? *YesNoUnsureAre you currently experiencing any of the following symptoms?Rate from 0 being no symptoms to 6 being severe symptomsHeadache *0123456"Pressure in the head" *0123456Neck Pain *0123456Nausea or vomiting *0123456Dizziness *0123456Blurred Vision *0123456Balance Problems *0123456Sensitivity to light *0123456Feeling slowed down *0123456Feels like "in a fog" *0123456Don't feel "right" *0123456Difficulty concentrating *0123456Difficulty remembering *0123456Fatigue or low energy *0123456Confusion *0123456Drowsiness *0123456Trouble falling asleep *0123456More emotional *0123456Irratibility *0123456Sadness *0123456Nervous or Anxious *0123456Ringing in ears *0123456Any other notes you would like your practitioner to know:If you have any questions please call us Red Deer Main: 403-314-4458Olds: 403-791-2766Red Deer Campus: 403-352-7979Submit
