100 Allstate Parkway #202, Markham, On. L3R 6H3
Phone: 647-335-6879

It is our hope that we can assist you with your current and future health concerns. During the course of your examination and treatments, please feel free to comment, ask questions, and provide us with feedback. We feel that the more you know and understand about yourself, the more effective your treatments will be.  We look forward to helping you achieve optimal health and well-being.

If you haven't already seen it - please watch our Introductory Video before filling out this form.

Please remember to wear stretchy, comfy clothes to your appointment, e.g. track pants or leotards.


New Client Form

The following client information is required

Date & Time of first appointment:
If you do not yet have an appointment set up, please call to arrange one BEFORE filling out this form.
Name of practitioner with whom appointment is scheduled:

First Name: Last Name:

Street Address1:

Street Address2:

City: Province/State:

Postal/ZIP Code: Country:

Home Phone: Work Phone: Cell Phone:  
NOTE: It is important that at least one phone number be provided so that we are able
to reach you for scheduling your care.

Email:

Age: Birthdate: Day: Mo: Yr:

Sex:

Marital Status: Number of Children:

Occupation:

Place of Birth:

If the client is a child, give the parent's names:
Mother: Father:
NOTE: for clients 12 and under please use the
Children's Health Questionnaire

Closest relative Phone # of closest relative

Medical Doctor: Doctor’s telephone:

How did you hear about Matrix Health Solutions ? Please be specific:

Chief reason for seeking care at Matrix Health Solutions :

Length of time for current condition:

Have you received other forms of therapy for this condition: 

Please specify:

Motor vehicle accident - If yes, date:

Work-related injury/accident - If yes, date:

Surgeries including dates:

Fractures/sprains including dates:

Hardware/Artificial Joints: Please specify:

Other injuries including dates:

Major illnesses including dates:

How is your general health?

Exercise (type/times per week):

Activities or positions that aggravate your symptoms.

Do you feel you are under excessive stress?

What are the things that you find stressful?

Do you have regular sleeping habits? How many hours?

Current Medications:


Additional relevant information:


Health History

Please select those conditions or symptoms which you currently have (C), which you have had previously (P), have had occasionally (O) or have never had (N).

C = Current P = Previous O = Occasionally N = Never

C

P

O

N

CARDIOVASCULAR

Angina

Bleeding disorders

Ankle swelling

Heart disease

Heart murmur

High blood pressure

Irregular heartbeat

Low blood pressure

Pacemaker

Poor circulation

Stroke


C

P

O

N

SKIN

Bruise easily

Bleed easily

Dryness

Eczema

Itching

Psoriasis

Rashes

Sensitivities

Varicose veins


C

P

O

N

INFECTIONS

AIDS

Hepatitis

Herpes

HIV

Infections skin conditions

Tuberculosis

C

P

O

N

EYE, EAR, NOSE AND THROAT

Difficulty swallowing

Earache

Hearing Loss

Hoarseness

Nosebleeds

Ear noises

Sinus pain

Vision problems


C

P

O

N

MEN

Decreased urinary flow

Dribbling after urination

Erectile dysfunction

Waking up to urinate

Inability to control bladder


C

P

O

N

WOMEN

Backache

Breast problems

Bladder dysfunction

Caesarian section

Cramps

Fibroids

Menopausal symptoms

Mid cycle pain

Ovarian cysts

Painful intercourse

Painful menstruation

Pregnancy*

PMS

Yeast infection

*If currently Pregnant, due date:

C

P

O

N

GENERAL

Alcohol/drug problem

Allergies

Arthritis

Blood in urine

Cancer

Constipation

Convulsions/
Seizure

Diabetes

Digestive problems

Dizziness

Esophageal reflux

Fainting

Fatigue

Fibromyalgia

Gall bladder problems

Headache

Hernia

Insomnia/sleep problems

Kidney problems

Liver problems

Mental disorders

Nervousness/
depression

Neuralgia

Osteoporosis

Spinal curvature


C

P

O

N

RESPIRATORY

Apnea

Asthma

Chronic cough

Difficult breathing

Snoring

 

Matrix Health Solutions will not share your information with anyone else.

NOTE: The following 2 boxes MUST be checked before submitting your form:

I have read and understand the and hereby agree to pay for services at the conclusion of each and every visit.

I understand cancellations and missed appointments without 24 hours notice will result in a fee of $60.

I have watched the Introductory Video.
I did find the Introductory Video helpful.


Please only click once on the submit button; thank you for your patience while the form is being processed.