Intake Form | Axion Health Portal

1

Patient Information

Date

How did you hear about us?

Legal Name*

Preferred Name

Date of Birth*

Gender / Pronouns

Health Card Number

Phone*

Email*

Address

City / Province / Postal Code

Occupation / Work Status

Emergency Contact Name

Relationship

Emergency Contact Phone

Family Physician / Primary Care Provider

Referring Doctor / Clinic

Preferred Pharmacy

2

Claim / Insurance / Billing Information (if applicable)

Billing type

Insurance Company

Policy / Member Number

Claim Number

Adjuster Name

Adjuster Phone / Email

Lawyer or Representative

Documents brought today (imaging, reports, claim paperwork, etc.)

3

Main Concerns and Chronic Pain History

4

Pain, Function, Sleep and Daily Life

5

Current and Past Treatments

6

Medications, Supplements, Allergies

List all current medications and supplements (name, dose, frequency, reason, prescriber)

Allergies or sensitivities (medications, latex, adhesives, foods, scents, other)

Substances (check all that apply)

7

Medical History

8

Red Flags and Safety Screening

9

Lifestyle, Supports and Mental Health

10

Consent to Proceed With Intake Review

I confirm that the information I provided is accurate to the best of my knowledge. I understand that this form does not replace a medical assessment, and I agree to tell the clinical team about changes in my health, medications, symptoms, pregnancy status, or safety concerns.

Print Name*

Date*

Signature *

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Parent / Guardian (if applicable)

Print Name