Chiropractic Intake Form

Chiropractic Intake Form

Affinity Health Clinic, 3 Waterloo Street, New Hamburg, ON N3A 1S3

Patient Name:

Healthcare provider:

Patient Information

Name:

Street Address: APT#

City: Prov. Postal code

Home Phone: Cell

Work Phone: ext. Fax

E-mail:

Birth Date (dd-mm-yy): Shoe Size:

Height: Weight:

Gender: Male Female

Marital Status: Single Married Separated Divorced Common law

Name of spouse/Significant Other:

Number of children:

Your occupation: Employer:

Who recommended our services to you?

Have you received chiropractic care previously?

If so, when? Name of practitioner:

For what reason?

Primary Health Concern

What is your primary reason for seeking our care? Please explain below.

When and how did this condition begin?

Was there an injury, trauma or health significant event that may be a contributing factor?

Did your condition happen: at work in a motor vehicle accident neither

Have you experienced a similar challenge in the past? If so, please explain below:

Have you been examined by another practitioner for this? Yes No

What was found and/or done?

Please indicate below the intensity of any discomfort you feel now:

Is your area of concern: getting better staying the same getting worse

Why do you think so?

What activities, factors or positions aggravate your symptoms?

How often do you experience your symptoms?

What, if anything, have you found to relieve or improve your symptoms?

Describe how it feels when the symptoms are at their worst?

Do your symptoms radiate to areas other than the primary area? If yes, where?

From 1 to 10, 10 being highest, rate your commitment to correcting this problem:

Lifestyle

Stress Level: Extreme High Moderate Low Absent

Please circle the types of stress that are or have been challenging for you:

Physical: Falls Accidents Injuries Repetitive Strain Poor Posture Birth trauma

Psychosocial: Loss of loved ones Move of home Work/School Mental/emotional abuse Family Financial/Legal Sexual abuse Change in relationship

Chemical: Tobacco Alcohol Coffee/Tea Recreational drugs Environmental toxins

In what position do you most commonly sleep? On your: Side Back Front

Rate your satisfaction with your sleep from 1 to 10 (10 being the best sleep):

List the forms of exercise and recreational activities in which you currently participate:

Rate your satisfaction with your diet from 1 to 10 (10 being very healthy):

Health Care History

Date of last:

Spinal Examination: Physical Examination:

Spinal X-Ray: Dental X-Ray:

Bone Mineral Density Test:

Please list all surgical operations you have had of any kind, why you had them, the net result and the approximate dates:

Please circle any of the following therapies that you have had done:

Acupuncture Chiropractic Counseling Dentistry Homeopathy Massage

Medicine Naturopathy Nutrition Podiatry Physiotherapy

Reflexology Reiki Shiatsu Traditional Chinese Medicine

If any of these therapies were of unique value or clearly detrimental, please give details:

Have you taken any steps personally, beyond the above, to improve your health?

For Women Only

Date of your last menstrual period:

Are you using any means of contraception:

With Respect to the questions below, please provide details where applicable, including dates:

Have you ever been knocked unconscious? Yes No

Have you ever used crutches, a walker or cane? Yes No

Please list your family members with diagnosed health conditions

Please list the medications, prescriptions and over-the-counter, you now use:

Please list the supplements (vitamins, minerals, homeopathic remedies, etc) you now use:

Health Conditions (Past and Present)

Please check each of the diseases or conditions that you have now (N) or have had in the past (P).

General: Allergy Convulsions Dizziness Fatigue Headache Loss of Sleep Loss of Weight Anxiety/Depression Numbness Cancer Diabetes Thyroid Problems Epilepsy Hyperactivity

Numbness or pain: Shoulders Upper arms Hands Legs Feet Poor Posture Swollen Joints Gout Polio

Eyes, Ears, Nose, Throat: Asthma Frequent Colds Crossed eyes Deafness Ear Infections Ringing in Ears Eye Pain Vision Problems Nasal Obstruction Sinus

Respiratory: Chest Pain Chronic Cough Irregular Breathing Wheezing Emphysema

Genito-Urinary: Bed-Wetting Painful Urination Prostate Trouble Blood in Urine Venereal Disease

Gastro-Intestinal: Constipation Diarrhea Digestive Dysfunction Gall Bladder Trouble Hemorrhoids Liver Trouble Ulcers

Cardio-Vascular: High Blood Pressure Low Blood Pressure Poor Circulation Irregular Heart Beat Ankle Swelling Anemia Arteriosclerosis Stroke

Women Only: Menstrual Cramps Irregular Cycle Hot Flashes Are you pregnant: Yes No

Muscle and Joint: Arthritis Hernia Low Back Pain Neck Pain Pain between shoulder blades

Other (not listed):