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2211 Riverside Drive, Suite 200
Ottawa, ON, K1H 7X5
Voice: 613.521.5355
Fax: 613.521.4189
Buttons X
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Patient Information
First Name
*
Date of birth
*
Last Name
*
Age
*
Address
*
Address Line 1
Address Line 2
City
Ontario
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon Territory
State / Province / Region
Zip / Postal Code
Canada
Country
Telephone (home)
*
Telephone (cell)
Telephone (work)
Email Address
*
Employer
Occupation
Address
How did you hear about this clinic?
Doctor
Internet
Friend
Other
Name of emergency contact
*
Telephone Number
Relationship
*
Are you here regarding injuries from a:
Recent motor vehicle accident
Yes
No
Work related accident / injury
Yes
No
Date
Date
Have you made a report of your accident to your employer
Yes
No
Name of medical doctor
Address
Address Line 1
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon Territory
State / Province / Region
Zip / Postal Code
Canada
Country
May we contact your medical doctor?
Yes
No
Date of last physical or visit to MD
Date of last dental exam
Have you ever been to a chiropractor
Yes
No
For what condition?
Were any X-rays taken
Yes
No
Where?
Results
Where and which body part?
When was your last appointment with the chiropractor?
Reason for leaving
Current health condition
Purpose of this appointment
What is your goal in coming to this clinic
Referencing the above image, indicate where you feel the described sensations (include all affected areas)
On a scale of 1-10 (10 being worst pain that you have ever felt), how would you rate your pain:
At best
-
+
0
1
2
3
4
5
6
7
8
9
10
At worst
-
+
0
1
2
3
4
5
6
7
8
9
10
Usual
-
+
0
1
2
3
4
5
6
7
8
9
10
When did this condition begin?
Anything associated with the onset?
What increases the pain?
What decreases the pain?
Any previous treatment for these complaints?
Since it started, is your condition the Same / Better / Worse
Same
Better
Worse
Do you have any other problems with bones / joints / muscles? Please describe
Past Health history
Medical problems / hospitalizations / treatment:
Previous surgeries:
Current medications / vitamins:
Allergies to drugs / medications:
Falls and accidents:
Ever unconscious?
For how long?
Any previous fractures?
Surgeries recommended but not performed:
Have you ever been treated for depression?
Yes
No
When?
Health and wellness screening questionnaire
Do you have any skin problems? Describe.
Do you have any nerve/psychiatric/psychological problems? Describe.
Do you have any problems with your eyes/ears/nose/throat? Describe.
Do you have any respiratory problems (asthma, bronchitis)? Describe.
Do you have any digestive problems (ulcer, irritable bowel, indigestion, constipation, hiatus hernia)? Describe
Do you have any urinary system problems (recurrent infection, prostate, kidney problems)? Describe
Do you suffer from frequent or intense headaches?
Yes
No
Cardiovascular system
Do you have a history of
High cholesterol
High blood pressure
Heart attack
Angina
Heart surgery
Diabetes
Has your mother, father, a brother, or sister developed heart problems before the age of 60?
Yes
No
Arthritis
Have you ever been diagnosed with arthritis?
Yes
No
Do you frequently suffer from joint pain, inflammation, or joint stiffness?
Yes
No
Questions for women only
Has your doctor ever indicated that you have osteoporosis?
Yes
No
Does osteoporosis run in your family?
Yes
No
Have you had a bone density test in the past two years?
Yes
No
Are you pregnant or planning pregnancy?
Yes
No
Do you have any problems with your breasts, menstrual cycle, Menopause?
Yes
No
If yes, please describe
Lifestyle Habits
Do you smoke?
Yes
No
How many packs per day?
Number of years
Do you consume alcohol?
Yes
No
Do you drink coffee?
Yes
No
Rate your diet:
Poor
Fair
Medium
Good
Excellent
How many glasses of water do you drink per day?
How many drinks per week?
How many cups per day?
Rate your appetite:
Poor
Fair
Medium
Good
Excellent
How many meals do you eat per day?
Do you have a history of repeated weight loss followed by weight gain?
Yes
No
Do you wear orthotics or foot supports?
Yes
No
How old are they?
Sleep
How many hours per night do you usually sleep?
Do you wake in the middle of the night?
Yes
No
Do you wake rested?
At what time?
How do you sleep? On your:
Side
Front
Back
Do you have sleep apnea?
Yes
No
Do you grind your teeth at night?
Yes
No
How old is your mattress?
Activities
How many days a week do you exercise inside
How many days a week do you exercise outside
What type of activities do you do?
Weights
Aerobics
Other
If other, please elaborate:
How often do you stretch?
Goals
What are your key wellness goals?
Osteoporosis prevention / management
Back strengthening and rehabilitation
Improved fitness
Arthritis management
Weight management
Other
Reduce heart disease risk factors (cholesterol, blood pressure)
If other, please elaborate:
What are you prepared to do to achieve these goals?
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