Personal Information

First Name *

Last Name *

Email Address *

Birth Date *

Gender *

Female

Male

Address *

City *

Province *

Country *

Postal Code *

Employer

Job Description *

Contact Information

I agree to receiving calls and/or having messages left at the following phone numbers:

Home Phone #*

Cell Phone #

Work Phone #

Family Information

Marital Status

Name of Spouse

Anniversary

# of children

Share Information

Would you like to give consent to anyone else to access your appointment and financial information? *

Yes

Insurance Details

Provincial Health Care Number *

In case of emergency contact:

Phone #

Referral

Who may we thank for referring you to our office? *

Chiropractic History

Have you been adjusted by a chiropractor before? *

Yes

Last adjusted:

Previous doctor:

Reason for previous visit:

Health History

Any past surgeries? *

Yes

Surgery details and dates:

Any major accidents in the past 5 years? *

Yes

Accident details and dates:

Have you had x-rays on your neck or spine in the past two years? *

Yes

Type of X-ray, date and location X-rays were done:

Have you had any pregnancies? *

Yes

Dates and outcomes:

Are you currently pregnant? *

Yes

Unsure

When are you due?

Are you currently taking any medication?*

Yes

Medications:

Your Visit

What is your reason for seeking chiropractic care? *

Do you currently have an open WCB claim? *

Yes

Please list WCB Claim Number and Adjustor contact information:

Is this a motor vehicle accident related injury? *

Yes

Has your insurance company been notified?

Yes

We use an electronic sign-in system in our office. In order to sign in we will provide you with a business card or a keychain, which would you prefer? *

Card

Keychain

Chief Complaint

Character of complaint: What does the pain feel like? (sharp, dull aching)*

Are there associated symptoms that affect others areas of your body? *

When and how did the problem first occur? *

Rate the intensity of pain: *

How often does the pain occur? *

Indicate locations of pain:

Does the pain start in one place and radiate elsewhere? (radiation) *

How long does the onset of pain last for? (duration) *

Does anything intensify the pain? (aggravating factors) *

Does anything relieve the pain? (relieving factors) *