First Name *

Last Name *

Occupation

Gender

DOB *

Height

Weight

Address *

City *

Zip / Postal code *

Email *

Would you like email appointment reminders?

Yes

No

Home Phone # *

Secondary Phone # *

Family Dr *

City

Doctor Phone #

Doctor Fax #

Referral Source *

Emergency Contact Name:

Emergency Phone # *

Relationship to patient

(If Applicable) WSIB (Workplace Injury) patients

Are you a WSIB patient? *

Yes

No

(If Applicable) MVA (Motor Vehicle Accident) Patients

Are you an MVA patient? *

Yes

No

Lawyer Information

Name of Law Firm

Name of Lawyer

Lawyer Address

Lawyer Phone #

Lawyer Fax #

Lawyer Email

Chiropractic Intake

Employer’s Information

Occupation

Employer

Medical History - indicate the health conditions that apply to you

Abdominal Pain

Chronic Pain

Infectious Conditions

Joint Pain/Stiffness

Sciatica

Thyroid Disease

Asthma

Diabetes

Heart Disease

Kidney Pain

Neck Pain/ Stiffness

Spinal Cord Injury

Varicose Veins

Fatigue/weakness

Hypertension

Low Back Pain

Poor Circulation

Stroke/Aneurysm

Cancer

Fracture

Headache

Osteoporosis

Scoliosis

Sprain/Strain

Other

Surgery and Trauma

Indicate your surgical history

1st Procedure

1st Procedure Year

2nd Procedure

2nd Procedure Year

3rd Procedure

3rd Procedure Year

4th Procedure

4th Procedure Year

5th Procedure

5th Procedure Year

Indicate any previous trauma and fractures

1st Previous Procedure

1st Previous Procedure Year

2nd Previous Procedure

2nd Previous Procedure Year

3rd Previous Procedure

3rd Previous Procedure Year

4th Previous Procedure

4th Previous Procedure Year

5th Previous Procedure

5th Previous Procedure Year

Family History - indicate the health conditions that apply to your family

Cancer

Diabetes

Stroke/Aneurysm

Heart Disease

Cholesterol

High Blood Pressure

Therapy Goals

Pain Relief

Flexibility

Improve Posture

Improve Posture

Core strength/endurance

Core strength/endurance

Have you tried treating your areas of concern before?

1st Treatment

1st Treatment Year

2nd Treatment

2nd Treatment Year

3nd Treatment

3nd Treatment Year

Write down the body parts where you feel pain or the sensation you are experincing.

I certify that the information above is accurate and I will advise the provider if my condition changes.

Signature

Clear

Date

Guardian (if under 18)